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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 4  |  Page : 2050-2056

Role of arthroscopy in the management of chronic lateral ankle instability


Department of Orthopedics and Traumatology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission29-Aug-2022
Date of Decision13-Oct-2022
Date of Acceptance22-Oct-2022
Date of Web Publication04-Mar-2023

Correspondence Address:
Mohammed A. A. Bahout
Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_297_22

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  Abstract 


Objectives
To evaluate the diagnostic role of ankle arthroscopy in the management of chronic lateral ankle instability and evaluation of clinical and functional outcomes of chronic lateral ankle ligament repair in the management of chronic lateral ankle instability.
Background
Ankle sprain is one of the most common injuries encountered in work and sport. It is caused by untreated or badly managed acute lateral ankle ligament injuries.
Patients and methods
This is a prospective study carried out on 24 patients, who were evaluated by diagnostic ankle arthroscopy prior to repair of chronic lateral ankle ligament, conducted in the Department of Orthopedics and Traumatology, Menoufia University Hospital between June 2020 and June 2021. Patients included in this study were evaluated by diagnostic ankle arthroscopy prior to repair/reconstruction of lateral ligaments of the ankle. All patients were postoperatively evaluated according to pain (visual analog scale score), range of motion, and functional scoring system (American Orthopaedic Foot and Ankle Society) score.
Result
Postoperatively, there was high statistically significant improvement in pain, function, and total American Orthopaedic Foot and Ankle Society scores. On the other hand, there was no statistically significant difference in alignment preoperatively and postoperatively.
Conclusion
The results of this study show the excellent efficacy of arthroscopic surgical procedures in the treatment of chronic lateral ankle instability.

Keywords: arthroscopy, instability, lateral, repair, sprain


How to cite this article:
Shahin AE, Bahout MA, El-Beheiry AM. Role of arthroscopy in the management of chronic lateral ankle instability. Menoufia Med J 2022;35:2050-6

How to cite this URL:
Shahin AE, Bahout MA, El-Beheiry AM. Role of arthroscopy in the management of chronic lateral ankle instability. Menoufia Med J [serial online] 2022 [cited 2024 Mar 28];35:2050-6. Available from: http://www.mmj.eg.net/text.asp?2022/35/4/2050/371024




  Introduction Top


Ankle sprains are among the most common athletic injuries representing about 50% of all lower extremity injuries in high school athletes [1]. Lateral ankle sprains typically occur from excessive inversion and internal rotation of the hindfoot while the leg is in external rotation [2].

Chronic ankle instability (CAI) may manifest clinically by episodes of giving way that lead to repeated ankle sprain; each of which is associated with a short period of pain and swelling and cumulatively leads to long-term deterioration in ankle function, athletic performance, and 78% posttraumatic ankle osteoarthritis [3].

The initial management of CAI consists of functional rehabilitation and use of bracing or taping [4]. Operative management of CAI is indicated in patients with failed 3–6-month conservative management because of either persistent pain or mechanical instability. This operative management for lateral CAI includes a variety of procedures ranging from simple repair to complex reconstruction [5].

Repair techniques include either reattaching or imbricating (shortening) the injured native tissues, whereas reconstruction techniques involve replacing the ligaments with either autograft or allograft tissue. Recently, ankle arthroscopy has gained popularity among orthopedic surgeons especially in the light of its technical advantages. In case of CAI, ankle arthroscopy can offer diagnostic tool for intra-articular ankle pathologic conditions such as osteochondral lesions of the talus, anterior ankle impingement, or a loose intra-articular body; in addition, it can aid in arthroscopically assisted ligament repair/reconstruction of lateral ankle ligamentous complex [6].

This study was conducted to evaluate the diagnostic role of ankle arthroscopy in the management of chronic lateral ankle instability and evaluation of clinical and functional outcomes of chronic lateral ankle ligament repair in the management of chronic lateral ankle instability.


  Patients and methods Top


This study was conducted in the Department of Orthopedics and Traumatology, Menoufia University Hospital between June 2020 and June 2021. Signed written well-informed patient consent was obtained from all patients. This study was approved by the Institutional Review Board [7] of Faculty of Medicine, Menoufia University. Patients' identification data were hidden and coded.

Patients more than 18 years old diagnosed with chronic lateral ankle instability with poor response to 6-month conservative management were enrolled in our study.

Patients less than 18 years, pregnant or lactating females with generalized joint laxity, generalized polyarthritis such as rheumatoid arthritis, comorbidities such as diabetes mellitus, referred pain; for example, spine pathology. Previous operative procedures of the ankle of interest, previous ORIF of ipsilateral lower extremity, associated ipsilateral deltoid ligament injury, and foot deformity were excluded from our study.

Preoperative data of the series includes history (age at operative intervention, sex duration of preoperative complaint, affected side, occupation); examination includes general examination, local examination (inspection for skin condition, scar, swelling, deformity, muscle atrophy, abnormal gait, palpation for tenderness over bony and soft tissue points, temperature, and preoperative range of motion); preoperative provocative tests include Varus stress test and anterior drawer test. Preoperative scoring system includes visual analog scale (VAS) score and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Postoperative imaging data includes radiograph (anteroposterior, lateral, and mortise views) and MRI.

Regarding operative procedure all patients were operated in supine position under spinal anesthesia and tourniquet control, and received a single dose (1 g) of third-generation cephalosporin injection with induction of anesthesia and then draped in a standard manner including the operated ankle. All patients were examined under anesthesia for range of motion, Varus stress test, and anterior drawer test. Diagnostic arthroscopy was performed through anteromedial, anterolateral portals. Operative interventions exercised in the current series were Brostrom repair technique and anatomic graft reconstruction.

Patients were followed up in the outpatient clinic through routine visits scheduled at 2nd, 4th, 6th, 8th, 12th, and 24th postoperative weeks for wound care, assessment of patient compliance with postoperative rehabilitation, and management of complication. All patients were postoperatively evaluated according to pain (VAS score), range of motion, and functional scoring system (AOFAS) score.

Statistical analysis

Data were collected, tabulated, and statistically analyzed using an IBM-compatible personal computer with Statistical Package for the Social Sciences [8], version 23 (SPSS Inc. Released 2015. IBM SPSS Statistics for Windows, version 23.0; IBM Corp., Armonk, New York, USA). Wilcoxon signed ranks test was used for comparison of different readings of data of nonnormal distribution in the same group. A P value of less than 0.05 was considered statistically significant.


  Results Top


Twenty-four patients were conducted in this study. The age of the patients at the time of operative intervention ranged from 18 to 60 years with a mean age of 33.63 ± 11.67 years. There were 10 (41.7%) males and 14 (58.3%) females with a male-to-female ratio of 0.71: 1. Duration of complaint ranged from 3 to 24 months with a mean duration of 11.04 ± 4.67 months. Workers were the most affected in 10 (41.67%) patients while students and housewives were affected in seven (29.17%) patients separately.

The preoperative mean range of motion was 40.0 ± 12.51° arc. There were six (25%) patients who had rotation of up to the 30° arc, 40° arc, and 50° arc separately while three (12.5%) patients had rotation of 20° arc and 60° arc, respectively. Regarding preoperative provocative tests, preoperatively, anterior drawer test was positive in 20 (83.3%) patients in our study with four (16.7%) had grade 2 and 16 (66.7%) had grade 3. Preoperatively, Talar tilt test was positive in 18 (75%) patients of this study.

Preoperative radiographic imaging showed Talar shift at Varus stress view in 20 (83.3%) patients and optical coherence tomography (OCT) in four (16.7%) patients. Preoperative MRI showed anterior talo-fibular ligament (ATFL) tear in 20 (83.3%) patients, calcaneofibular ligament (CFL) in two (8.3%) patients, and OCT in three (12.5%) patients.

Arthroscopic finding recorded eight (33.3%) patients had osteochondral defect (OCD), two (8.3%) patients had loose body, one (4.2%) had anterior osteophytes, 20 (83.3%) patients had tear of ATFL, and 11 (45.8%) patients had synovitis [Table 1].
Table 1: Distribution of included patients regarding arthroscopic findings

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Regarding the type of operative intervention repair of ATFL (modified Brostrom) was done in 13 (54.17%) patients, arthroscopic microfracture in two (8.3%) patients, osteophytectomy in one (4.2%) patient, reconstruction of lateral ligaments by hamstring graft in six (25%) patients, removal of loose body in one (4.2%) patient, and synovectomy in eight (33.3%) patients [Table 2].
Table 2: Distribution of included patients according to the type of operative intervention

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The preoperative scoring systems: preoperative pain score mean value was 19.58 ± 8.59 points; preoperative function score mean value was 21.25 ± 10.35 points. Preoperative alignment score was 10 points in all patients on the AOFAS scale. Preoperative overall total score ranged from 30 to 70 points on the AOFAS scale with a mean value of 50.83 ± 13.16 points. Preoperative pain on VAS score ranged from 6 to 8 points with a mean value of 7.25 ± 0.737 points.

There were seven (29.2%) patients who had positive anterior ankle impingement and 17 (70.8%) patients had negative anterior ankle impingement. There were eight (33.3%) patients had positive OCT and 22 (91.7%) patients had negative OCT. There were 11 (45.8%) patients who had positive synovitis and 13 (54.2%) patients had negative synovitis. There were two (8.3%) patients who had loose body and 22 (91.7%) patients who had no loose body. ATFL tear was found in 20 (83.3%) patients while CFL tear was found in one (4.2%) patient. Repair of ATFL (modified Brostrom) was the most common surgery that was performed for 13 (54.17%) patients.

There were two (91.7%) patients who suffered from pain and one (4.2%) patient suffered from swelling. There was a negative correlation between patients' age and function of AOFAS scale postoperatively. Younger patients had better results than older patients. This correlation was statistically significant. There was a statistically insignificant correlation between sex and AOFAS scale preoperatively and postoperatively.

The postoperative range of motion became full. Six months postoperatively, there was statistically significant improvement in the range of motion in all patients. Postoperatively, there was high statistically significant improvement in pain, function, and total AOFAS scores. On the other hand, there was no statistically significant difference in alignment preoperatively and postoperatively.

Postoperative pain on VAS score ranged from 6 to 8 points with a mean value of 7.25 ± 0.737 points. Postoperatively, there was statistically significant improvement in pain of VAS score.

Statistically, there was high significant improvement in pain, function, and total AOFAS scores. On the other hand, there was no statistically significant difference in alignment preoperatively and postoperatively [Table 3].
Table 3: Comparison between preoperative and postoperative follow-up of American Orthopaedic Foot and Ankle Society scale

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  Discussion Top


CAI may develop after one or more ankle sprains, regardless of the severity of the injury. CAI occurs in about 20% of patients with ankle sprains. ATFL tears are the most common lesions in patients with CAI, as the ATFL is both the weakest ankle ligament and the primary ankle stabilizer in plantar flexion [9].

The main aim of this study was to evaluate the diagnostic role of ankle arthroscopy in the management of chronic lateral ankle instability and evaluation of clinical and functional outcomes of chronic lateral ankle ligament repair in the management of chronic lateral ankle instability.

The present study showed that age of the patients at the time of operative intervention ranged from 18 to 60 years with a mean age of 33.63 ± 11.67 years. There were 10 (41.7%) males and 14 (58.3%) females with a male-to-female ratio of 0.71: 1. Duration of complaint ranged from 3 to 24 months with a mean duration of 11.04 ± 4.67 months.

However, in the study of Matsui et al.[10] on a cohort of 37 patients, surgery was performed for 18 feet of 18 patients in group O (open procedure) and 19 feet of 19 patients in group A (arthroscopic repair). There was no significant difference in baseline characteristics between the two groups.

Li et al.[11] studied 23 patients who underwent an arthroscopic repair procedure (arthroscopic group) and 37 patients who underwent an open repair procedure (open group). No significant difference was found in age, BMI, sex, injury time, or follow-up time between groups.

While female sex has been previously associated with higher incidence rates of ankle sprain, studies evaluating sex disparity in acute ankle instability incidence have yielded mixed results. The United States Military Academy revealed an incidence rate for ankle sprain among female cadets of 96.4 per 1000 person-years in contrast to an incidence rate of 52.7 per 1000 person-years among male cadets (incidence rate ratio 1.83). When examining the subset of intercollegiate athletes, no difference was detected by sex after controlling for athletic exposure and individual sport [12]. Beynnon et al.[13] reported an incidence rate of ankle sprain of 1.6 per 1000 person-days for male college athletes, compared with 2.2 per 1000 person-days for female college athletes, although the reported disparity did not achieve statistical significance. Hosea et al.[14] also reported a 25% greater risk for sustaining less severe (grade I) ankle sprains for female high school and college basketball players, than their male counterparts. They did not, however, find a statistically different incidence of more severe ankle sprains among the same population.

The present study showed that the mean preoperative range of motion was 40.0 ± 12.51° arc. Preoperatively, anterior drawer test was positive in 20 (83.3%) patients in our study with four (16.7%) of grade 2 and 16 (66.7%) of grade 3. Preoperatively, talar tilt test was positive in 18 (75%) patients of this study.

While in the study of Thès et al.[15], all 69 ATFLs were classified as abnormal (none was grade 0) and matched the description one of the grades 1–4. Distribution of grades was as follows: 1, 21% (range, 20.3–21.7%); grade 2, 25.0% (20.3–29.0%); grade 3, 37.3% (27.5–50.7%); and grade 4, 16.7% (5.8–23.2%).

Our results showed that preoperative radiographic imaging showed talar shift at Varus stress view in 20 (83.3%) patients and OCT in four (16.7%) patients. Preoperative MRI imaging showed tear of ATFL in 20 (83.3%) patients, CFL in two (8.3%) patients, and OCT in three (12.5%) patients.

However, in the study of Yeo et al.[16] as regards radiologic outcomes, the mean anterior talar translation showed significant improvement, from 8.4 mm (SD = 2.9) preoperatively to 6.7 mm (SD = 1.3) at the final follow-up in the all-inside arthroscopic modified Broström operation (MBO) group, and from 7.8 mm (SD = 1.9) preoperatively to 6.8 mm (SD = 2.06) at the final follow-up in the open MBO group. The mean talar tilt improved from 7.3 (SD = 4.3) preoperatively to 3.9 (SD = 1.51) at the final follow-up in the all-inside arthroscopic MBO group, and from 5.4 (SD = 4.16) preoperatively to 3.8 (SD = 3.61) at the final follow-up in the open MBO group. Radiographic data showed no significant difference between the two groups (P = 0.39 and 0.436, respectively).

In the study of Li et al.[11] in the arthroscopic group, five patients had OCD and one patient had osteophyte. In the open group, 12 patients had OCD and five patients had osteophyte. No significant difference was found between the arthroscopic group and the open group regarding the incidence of OCD (22 vs. 32%) or osteophyte (4 vs. 14%). For patients with osteophyte, debridement was performed. In the arthroscopic group, debridement was performed in one patient and microfracture was performed in four patients. In the open group, debridement was performed in one patient and microfracture was performed in nine patients.

The current study reported, postoperatively, that there was high statistically significant improvement in pain, function, and total AOFAS scores.

Postoperative pain on VAS score ranged from 6 to 8 points with a mean value of 7.25 ± 0.737 points.

Our results were supported by the study of Matsui et al.[10] as they reported that there was no difference in the mean VAS score at 2 weeks after surgery: 12.4 points (range, 0–55) in group A versus 19.2 points (range, 4–62) in group O. There was no significant difference in mean time to return to sports activities: 16.5 weeks (range, 12–22) in group A versus 17.1 weeks (range, 13–22) in group O. The talar tilt angle and displacement of the talus were significantly improved after surgery in both groups, and there was no significant difference in these parameters between the groups.

In the study of Yeo et al.[16] the AOFAS, VAS, and the Karlsson scores were improved significantly in both groups at the final follow-up evaluation. Comparing the final follow-up postoperative clinical scores between the two groups, there was no difference in AOFAS, VAS, or Karlsson scores between the two groups.

Today, the open MBO is the standard procedure for treatment of chronic lateral ankle instability, but arthroscopic techniques for lateral ankle instability are increasingly being used to repair the lateral ligament complex of the ankle. Kim et al.[17] reported on 28 ankles and the AOFAS score at the final follow-up was increased compared with the preoperative score, and the anterior drawer test score was significantly improved.

Nuno and Moreira [18] reported on 31 patients for whom the average postoperative AOFAS score was 85.3, and the satisfaction was 3.8, although they did not report preoperative scores. Nery et al.[19] reported on 38 patients where the mean AOFAS score was 90 at the last follow-up, the anterior drawer test showed grade 0 laxity in 25 patients and grade 1 in 13 patients, and the mean talar tilt on the operated side was 2.7 mm (range, 0.4–8 mm), compared with 2.4 mm (range, 0.4–7 mm) on the uninjured side. Acevedo and Mangone [20] reported on 93 patients with Karlsson-Peterson scores having improved substantially from a preoperative mean of 28.3 to a postoperative mean of 90.2, and 69 of 73 patients were satisfied with the results, whereas four were dissatisfied.

However, Drakos et al.[21] conducted a biomechanical comparison between open and arthroscopic procedures for ankle instability. No difference in stability was reported. Giza et al.[22] randomly performed open and arthroscopic procedures on the ankles of seven pairs of matched cadavers, and applied external force until rupture occurred. Degree of failure was measured, and there was no difference in the results between the two groups.

The meta-analysis conducted by Brown et al.[23] showed that 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 arthroscopic repair. There was no statistically significant difference in Karlsson score.

In the study of Maiotti et al.[24], the average preoperative measurements of anterior talar translation and talar tilt on the pathologic ankles were 6.8 ± 0.6 mm (range, 6–8 mm) and 11.2°±1.0° (range, 10°–14°). Postoperative radiographic measurements at a mean follow-up after the procedures revealed an average talar translation of 3.1 ± 1.2 mm (range, 1–5 mm) with a reduction of 3.7 ± 1.0 mm. The average postoperative measurement of talar tilt was 4.2°±1.7° (range, 2°–7°) with a reduction of 6.9°±1.5°. Karlsson and Peterson postoperative score ranged from 70 to 98 points (mean, 89.3 points), and the mean increase was 37.2 ± 6.8. Excellent or good results were achieved in 19 (86.3%) ankles, two had a fair result, and only one was poor.

Various surgical approaches for anatomic repair or reconstruction of the ATFL provide good clinical results. The open modified Broström anatomic repair technique using suture anchors is widely accepted as the reference standard for the treatment of chronic lateral ankle instability, as this procedure allows immediate weight-bearing and returns high-demand athletes to their preinjury level of sports. Furthermore, many investigations have reported arthroscopic repair of the ATFL for the treatment of CAI [25].

The present study showed that most of the patients had no complications. There were two (91.7%) patients suffered from pain and one (4.2%) patient suffered from swelling. There was a negative correlation between patients' age and function of AOFAS scale postoperatively. Younger patients had better results than older patients. This correlation was statistically significant. There was a statistically insignificant correlation between sex and AOFAS scale preoperatively and postoperatively.

However, in the study of Matsui et al.[10] two patients had temporary numbness of the superficial peroneal nerve in group A, while three patients had wound irritation and one patient had temporary numbness of the superficial peroneal nerve in group O. There was no recurrence of ankle instability in either group.

In the meta-analysis conducted by Brown et al.[23], there was no statistically significant difference between arthroscopic repair and wound repair with regard to complication rate or wound complications.

Giza et al. [22] found no difference in strength, stiffness, or degrees to failure between the two surgical techniques. The arthroscopically repaired group showed a similar failure pattern to the open fixation group, such that the majority of repairs failed at the ligament–suture interface.

According to Yeo et al.[16] in the all-arthroscopic group, two patients had superficial peroneal nerve injuries, and one patient had a sural nerve injury; symptoms subsided by postoperative 3 months. Two patients had knot pain; one improved and the other had a knot removal operation at month 6, after which symptoms subsided.

Furthermore, Lee et al. [26] revealed that there was also no significant difference in the degrees to failure between the open and arthroscopic MBOs.


  Conclusion Top


The results of this study show the excellent efficacy of arthroscopic surgical procedures in the treatment of chronic lateral ankle instability.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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