PurposeThis study compares the clinical outcomes of the Lasso-loop and Jaw-designed suture passer techniques for arthroscopic treatment of chronic lateral ankle instability (CLAI) caused by anterior talofibular ligament (ATFL) injuries. We aimed to assess whether the Jaw-designed technique provides similar outcomes with reduced intraoperative stitch time.MethodsThis retrospective cohort study included 40 patients with CLAI, who underwent arthroscopic ligament repair between February 2019 and February 2022. They were divided into two groups: 20 treated with the Lasso-loop technique and 20 with the Jaw-designed suture passer. Functional outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) scale, Karlsson Ankle Functional Score (KAFS), Tegner activity scale (TAS), and Visual Analog Scale (VAS) for pain. Intraoperative ligament stitch time was also recorded for both groups.ResultsBoth groups showed significant improvement in AOFAS, KAFS, TAS, and VAS scores from preoperative to final follow-up (p < .001). The mean intraoperative ligament stitch time was significantly shorter in the Jaw-designed group (9.1 min) compared to the Lasso-loop group (16.5 min) (p < .001). However, no significant differences in final functional outcomes (AOFAS, KAFS, TAS, and VAS scores) were observed between the two groups (p > .05).ConclusionThe Jaw-designed suture passer technique for repairing the ATFL in CLAI offers clinical outcomes comparable to the Lasso-loop technique, with the added benefits of a shorter suture time and simpler execution. This technique may be particularly beneficial for novice surgeons and can serve as a reliable alternative to the Lasso-loop suture technique in the arthroscopic repair of CLAI.

Syndesmotic injuries are common football injuries. The unique demands of football athletes create large magnitude rotational moments about the ankle, even during low impact maneuvers. This review explores the structure and function of the syndesmosis, assesses recent data in football athletes at the professional and collegiate levels regarding epidemiology, describes available treatment options, and provides example cases from the authors' institution. The review concludes with clinical and surgical pearls for the evaluation and treatment of syndesmotic injury.

In general, flexible syndesmotic fixation has demonstrated similar clinical outcome scores as rigid fixation. Flexible fixation has demonstrated benefit over rigid fixation in terms of implant failure, hardware removal, and local irritation. Both flexible and rigid fixation remain viable options for treatment of syndesmotic injuries yet the indications for selecting a construct are often subjective. Certain cases of high-risk football players such as linemen may warrant careful consideration of rigid fixation options despite the clinical advantages of flexible fixation. During fixation, direct visualization techniques with open or arthroscopic assistance for reduction of the syndesmosis remain superior and enable diagnosis of chondral defects. Flexible and rigid syndesmotic fixation techniques are viable for treatment of unstable syndesmotic injuries in athletes. Recent literature favors flexible fixation. However, at-risk football athletes or those with length unstable fibula fractures may benefit from rigid or supplemental flexible fixation as opposed to traditional flexible fixation. We recommend direct visualization of reduction at the syndesmosis during surgical treatment of unstable ankle injuries.

Total talar replacement (TTR) with an additively manufactured personalized total talar prosthesis (TTP) is an emerging treatment for ankle disorders. However, how to enhance the ankle stability after TTR, which usually raises the ankle instability, has not been explored. This study constructed a set of specific numerical models to investigate the effects of TTR and oversized TTPs on the ankle stability, including inversion, eversion, and anterior stability. The oversized TTPs include TTP-FP1.5 and TTP-FP3 scaled the identical TTP0 by 1.5% and 3.0% along the frontal axis, and TTP-VP1.5 and TTP-VP3 scaled TTP0 by 1.5% and 3.0% along the vertical axis. The numerical results identify that under varus/valgus force, the TTP-FP1.5 and TTP-FP3 produce smaller talar tilt angles compared with that of TTP0, as the inversion and eversion stability are significantly enhanced. Furthermore, TTP-VP1.5 and TTP-VP3 can provide larger contact force to the tibia, providing better anterior stability under anterior drawer force. Additionally, the increased contact force of TTP-VP1.5 and TTP-VP3 with the tibial cartilage enhances the eversion stability. Besides, the increase of TTP size along the vertical axis will weaken the inversion stability under low loads, as this scaling might have compromised the stability of the subtalar joint. The present numerical study systematically investigates the effect of different ways of increasing TTP size on ankle stability after TTP.

Ankle sprains in American football resulting from external rotation and eversion (EE) mechanisms remain a persistent injury that often involves player-to-player contact. Currently, there is little research that describes the frequency or source of this contact in American football and what scenarios are responsible for these injuries across different player positions.

To identify injury scenarios of ankle sprains that result from EE mechanisms in the National Football League (NFL).

Descriptive epidemiology study.

Ankle sprains reported during NFL games over 4 consecutive seasons (2017-2020) were identified through a query of the NFL Electronic Medical Record by an independent epidemiological company based on a set of clinical impression codes. Injuries with available video to view the injury enabled the identification of ankle sprains that resulted from EE mechanisms. Standardized terminology was developed to systematically describe and categorize each injury.

A total of 257 ankle sprains resulting from EE mechanisms were identified from a review of 670 ankle sprains and grouped into 8 standardized injury scenarios. Direct contact to the injured player's foot, ankle, or leg from a large external mass, such as an opponent's pelvis, accounted for 79% of reviewed injuries. Direct contact from a large external mass was the most common scenario for all positions except safeties, and 83% of running back injuries were the result of a tackle. Only 15% of injuries reviewed resulted from injury scenarios in which injurious loading was transmitted solely through the cleat-surface interaction. Safeties and cornerbacks were more commonly involved in these nondirect injury scenarios, such as change of direction, where current interventions may prove more effective.

EE ankle sprains were observed to occur from 8 different injury scenarios that varied by player position. Interventions through training, bracing, or changing cleat-surface interaction may not be effective for all injury scenarios. Tackling technique may be a unique intervention for running backs.

The aim of this study is to review the variation in description of the individual bands comprising the deltoid and spring ligaments in anatomical dissection studies and to propose a novel approach to describe the structure. A literature search for cadaveric studies identifying anatomical variations in the deltoid and spring ligament complexes was conducted using PubMed and Medline databases. The inclusion criteria encompassed human cadaveric dissection studies with measurement of individual deltoid and spring ligament bands in the English language and with full-text availability. The following studies were excluded: animal studies, articles describing surgical repair approaches, and radiological assessment studies without cadaveric dissection. The demographic data, parameters of individual components, as well as the morphological structure of individual deltoid bands were summarised. Out of the 18,208 studies from the database search, 11 articles were included in this study. Thirteen additional studies were obtained from the bibliographies, resulting in a total of 24 studies with 528 ankles evaluated. Due to the complexity of their anatomical relationships, the deltoid and spring ligaments should be described as a single entity: the "deltoid-spring ligament complex". Its gross morphology can be described as triangular, trapezoidal, and rectangular. It can be differentiated into the deep deltoid and the superficial deltospring ligament, which are connected. The latter encompasses the superficial deltoid and superomedial part of the spring ligament. The deep plantar ligament and "the inferior spring ligament" are separate entities reflecting their discrete natures and histological differences. The superficial deltospring ligament can be divided into contiguous segments with variable bands (thickening but not true ligaments). Each segment can be clinically assessed en masse. This description can help to clarify the nomenclature.

Each band of the deltoid ligament cooperatively contributes to stability of the medial side of the ankle joint. Investigating the function of each band of the deltoid ligament is essential to assess abnormalities and develop treatment options.

To evaluate the changes in ankle kinematics when each band of the deltoid ligament is injured and to measure the in situ force of each ligamentous band in intact ankle kinematics.

Descriptive laboratory study.

A total of 8 healthy fresh-frozen cadaveric legs were examined by applying forces through eversion and external rotation of the ankle joint using a 6 degrees of freedom robotic system. The deltoid ligament was separated into 6 discrete bands: tibionavicular ligament, tibiospring ligament, tibiocalcaneal ligament (TCL), anterior tibiotalar ligament, superficial posterior tibiotalar ligament (sPTTL), and deep posterior tibiotalar ligament; the bands were then sequentially transected. A loading test was performed in each model, and the changes in ankle motion and in situ force of each ligamentous band were measured using the robotic system.

When an eversion force was applied to the intact ankle, the in situ force of the sPTTL was 21.6 N in dorsiflexion and that of the TCL was 19.4 N in plantarflexion, both of which were significantly greater than those of the other ligamentous bands. Additionally, the amount of eversion under eversion loading increased significantly by 3.3° with sPTTL resection in dorsiflexion and by 4.2° with TCL resection in plantarflexion.

The TCL and sPTTL play important roles among the ligamentous bands of the deltoid ligament. The sPTTL played a more significant role in ankle dorsiflexion, whereas the TCL played a more significant role in ankle plantarflexion.

The TCL and sPTTL should receive attention in the treatment of deltoid ligamentous injuries.

The anterior drawer test of the ankle is widely used to diagnose anterior talofibular ligament injuries caused by ankle sprains; however, low sensitivity has been reported. The braking effect of the deltoid ligament is likely responsible for this low sensitivity. This study aimed to examine the effect of consistent and mandated internal rotation of the hindfoot, which leads to relaxation of the deltoid ligament, on the conventional anterior drawer test.

Seven cadaveric ankle specimens were subjected to quantitative analysis with a stretchable strain sensor at 30° plantarflexion, with or without 10° internal rotations, under accurate three-axial joint angle monitoring using inertial measurement units. The anterior drawer distance (mm) was calculated from the measured change in the capacitance value (picofarad) detected using the stretchable strain sensor and compared with that measured with the anterior talofibular ligament detached.

A two-way repeated measures analysis of variance and post-hoc pairwise analysis revealed that the anterior drawer test with internal rotation revealed a significantly greater mean value than the conventional anterior drawer test (4.7 ± 1.6 mm vs. 2.2 ± 1.5 mm) in anterior talofibular ligament-detached samples (P < 0.001). The capacitance data revealed an intraclass correlation coefficient (1,1) of 0.903.

Present findings suggest that our modified anterior drawer test with consistent and mandatory internal rotation, prevents the braking effect of the deltoid ligament and is expected to improve the sensitivity in assessing anterior talofibular ligament injuries.

The tibiofibular syndesmosis is essential for preserving the stability of the ankle. Acute syndesmotic injuries with evident or latent instability usually warrant surgical interventions. This cadaveric study examines and compares biomechanical characteristics between the following treatments for syndesmosis injuries: suture-button fixation plus syndesmotic repair and screw fixation.

The lower extremities of 10 cadavers disarticulated at the knee joints were used, yielding 20 feet. Ten feet underwent surgery using the suture-button fixation with syndesmotic repair, while the remaining 10 feet underwent surgery using screw fixation. Before surgical treatment of syndesmosis injuries, each cadaveric lower limb underwent preliminary physiological cyclic loading, which was followed by a series of postfixation cyclic loading tests after the surgical procedure.

Our principal finding is that suture-button fixation with syndesmotic repair provided torsional strength comparable to that of screw fixation. The mean failure torque did not differ between the 2 groups, but the rotational stiffness was significantly lower in the suture-button fixation/augmentation group.

Suture-button fixation/augmentation facilitates flexible (physiological) syndesmosis movement and may be a useful alternative treatment for ankle syndesmosis injury.

Background: Syndesmotic instability presents a significant challenge in orthopedic surgery, with no universally accepted treatment approach. Traditional methods, such as trans-syndesmotic screw fixation, remain widely used but are associated with complications, including malreduction, hardware-related issues, and restricted physiological motion. Recent advancements in flexible dynamic fixation, particularly suture tape augmentation, offer promising alternatives by preserving native biomechanics and enabling early rehabilitation. Methods: This technical note details an anterior-to-posterior syndesmotic augmentation technique using suture tape to address unstable syndesmotic injuries involving both the anterior inferior tibiofibular ligament and posterior inferior tibiofibular ligament. The proposed technique aims to restore stability, reduce complications, and improve functional outcomes. Results: The technique eliminates the need for hardware removal, supports early weight-bearing, and minimizes postoperative limitations. Conclusions: Anterior-to-posterior syndesmotic augmentation with suture tape represents a viable alternative for syndesmotic instability. Further clinical and biomechanical studies are warranted to validate its long-term efficacy and applicability across diverse patient populations.

The anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) are vulnerable to be torn or ruptured during lateral ankle sprain (LAS), especially in people with chronic ankle instability (CAI). This study aims to determine whether landing with a larger toe-out angle would influence ATFL and CFL strains in people with CAI, aiming to contribute to the development of effective landing strategies to reduce LAS risk.

Thirty participants with CAI (22 males and 8 females, age: 21.6 ± 1.5 years, height: 175.3 ± 7.1 cm, body mass: 70.8 ± 7.1 kg, mean ± SD) were recruited. Each participant landed on a specialized trap-door device with their unaffected limbs on a support platform and their affected limbs on a movable platform, which could be flipped 24° inward and 15° forward to mimic LAS conditions. Two landing conditions were tested-i.e., natural landing (NL, with natural toe-out angle at landing) and toe-out landing (TL, with toe-out angle increased to over 150% of that under the NL conditions). Kinematic data were captured using a 12-camera motion analysis system, and ATFL and CFL strains were calculated using a 3D rigid-body foot model. Paired sample t tests and Pearson's correlations were used to analyze data.

Compared to NL conditions, ATFL strain decreased (p < 0.001, d = 2.42) while CFL strain remained unchanged (p = 0.229, d = 0.09) under TL conditions. The toe-out angle was negatively and strongly correlated with ATFL strain (r = -0.743, p < 0.001) but not with CFL strain (r = 0.153, p = 0.251). Compared to NL conditions, participants exhibit a lower ankle inversion angle (p < 0.001, d = 0.494), a higher plantarflexion angle (p < 0.001, d = 1.101), and no significant difference in external rotation angle (p = 0.571, d = 0.133) under TL conditions.

Toe-out landing may reduce ATFL strain while maintaining CFL strain in people with CAI, thereby reducing the risk of LAS.

Total talus replacement has been demonstrated to increase ankle instability. However, no studies have explored how to enhance postoperative stability. This study aims to explore the effect of collateral ligament reconstruction on ankle stability by finite element analysis. The results identify that the reconstruction of the posterior talofibular ligament or anterior tibiotalar ligament has little effect on ankle stability. Besides, the reconstruction of the posterior tibiotalar ligament can significantly enhance the eversion stability. Additionally, the traction force of the fibula on the total talar prosthesis after reconstruction of the anterior talofibular ligament can significantly enhance ankle inversion and anterior stability.

Posterior malleolus fractures may be fixed to restore syndesmosis stability. However, these fractures are often accompanied by ruptures of other ligaments that stabilize the syndesmosis. This study investigates the frequency of anterior syndesmosis injury in posterior malleolus fractures and its effect on rotational stability.

Seventy-five consecutive patients who underwent surgery for ankle fractures involving posterior malleolus were prospectively included. Preoperative computed tomography scans in two planes (transverse and sagittal) were used to assess the presence and size of avulsion fractures (LeFort-Wagstaffe and Tillaux-Chaput). Intraoperatively, anterior syndesmosis injuries and rotational stability (determined via the external rotation test) were assessed through direct visualization.

In 73 patients (97%), a complete injury of the anterior tibiofibular ligament was observed intraoperatively, manifesting as avulsion fractures (8%), ligament injuries (44%), or a combination of both (45%). The mean dimensions of the avulsion fractures were 12.6 mm × 7.5 mm for LeFort-Wagstaffe fractures and 12.4 mm × 7.9 mm for Tillaux-Chaput fractures. Posterior malleolus fractures were stabilized in 57 patients. In 52 of these cases (92%), syndesmosis instability in the direction of external rotation persisted despite fixation of the posterior malleolus.

Fixation of posterior malleolus fractures is rarely sufficient to fully restore syndesmosis stability. Post-fixation assessment of syndesmosis stability, particularly in external rotation, is essential.

The lateral ankle ligament complex, consisting of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL), is essential for ankle stability. While the ATFL and CFL are frequently studied, the PTFL's role remains less explored.

Twelve fresh-frozen ankle specimens were dissected to analyze the PTFL's origin, trajectory, and talar insertion, focusing on its bundles and anatomical relationships.

All specimens exhibited a consistent PTFL origin at the lateral malleolar fossa. Two distinct bundles were identified: the pars superficialis (PS) and pars profunda (PP). The PS attached to the posterolateral talus, while the PP attached separately to the posterior aspect of the lateral talar process.

The PTFL comprises two distinct bundles with separate talar insertions. This finding challenges the traditional view of a single-bundled PTFL and may influence understanding of lateral ankle instability as well as its treatment.

IV.

Chronic ankle instability is frequent complication following ankle sprains. Anatomical reconstruction of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) with a gracilis autograft is a validated reconstruction technique. The signal-to-noise quotient ankle (SNQA) score evaluates graft maturation with MRI and has been shown to be reproducible and reliable. The goal of this study was to evaluate the process of ligamentization of the anatomical reconstruction of the ankle using the SNQA. The hypothesis was that the SNQA signal of the ATFL and the CFL would decrease over time.

A prospective cohort of patients who underwent arthroscopic anatomical ATFL-CFL reconstruction was included. All patients underwent a follow-up MRI examination 3, 6. and 12 months after surgery and the SNQA score was determined.

Twenty consecutive patients were included. The SNQA score decreased significantly over time for the ATFL (p = 0.001), the CFL (p < 0.001) and for the fibular bone tunnel-graft interface (p = 0.02). The SNQA scores of the ATFL were significantly higher than those of the CFL at 3 months (p = 0.01), 6 months (p = 0.003) and 12 months (p < 0.001), and then those of the fibular tunnel-graft interface at 12 months (p = 0.003). There was no difference in the SNQA score between the CFL and in the fibular graft-bone tunnel interface at any of the follow up periods.

There is a process of graft maturation following anatomical ATFL and CFL reconstruction over time, which is faster for the CFL than for the ATFL during the first year.

II.

Currently, there are various surgical options for the treatment of lateral ankle sprains, and deciding which surgical option to use is a question worth considering. Furthermore, there is a relative scarcity of mechanical research comparing suture anchor repair (SAR) and suture tape augmentation (STA) internal brace for the repair of the anterior talofibular ligament (ATFL). Therefore, this study aimed to compare the efficacy of arthroscopically all-inside ATFL SAR and STA for reconstruction to treat lateral ankle sprains through biomechanical testing.

Eighteen fresh-frozen cadaver ankles were used for the study and divided into one of three groups: (1) intact ATFL group, (2) arthroscopically reconstructed with suture tape augmentation internal brace of the ATFL (STA group), and (3) arthroscopically repaired ATFL with suture anchors (SAR group). We used custom fixtures to test the specimens for loading to ultimate failure and stiffness.

The mean load to failure of the STA group (311.20 ± 52.56 N) was significantly higher than that of the intact ATFL group (157.37 ± 63.87 N; p = 0.0016) and the SAR group (165.27 ± 66.81 N; p = 0.0025). The mean stiffness of the STA group (30.10 ± 5.10 N/mm) was significantly higher than that of the intact ATFL (14.17 ± 6.35 N/mm; p = 0.0012) and the SAR group (15.15 ± 6.89 N/mm; p = 0.0021). The suture anchor repair withstood failure loads and stiffness similar to the intact ATFL.

In terms of failure load and stiffness, the reconstructive outcome of ATFL reconstruction with STA is markedly superior to that of SAR reconstruction of the ATFL and the intact ATFL. Additionally, the novel technique of the SAR was a reliable technique that offered biomechanical properties similar to intact ATFL.

Ankle sprains are the most common lesion of the ankle joint which might result in chronic ankle instability (CAI). Significant strides have been taken to enhance our comprehension of the underlying mechanisms of CAI, as the exploration of novel surgical techniques and the identification of previously unrecognized anatomical components. The present review aims to provide an extensive overview of CAI, encompassing its pathophysiology, epidemiology, clinical assessment, treatment, and rehabilitation. Treatment of CAI requires a multifaceted algorithm, involving historical analysis, clinical evaluations, and diagnostic imaging. Surgical interventions for CAI primarily involve the anatomical and/or non-anatomical reconstruction and/or repair of the anterior talofibular ligament. Anatomical repair has exhibited superior functional outcomes and a reduced risk of secondary osteoarthritis compared to non-anatomical repair. Non-anatomical approaches fall short of replicating the normal biomechanics of the anterior talofibular ligament, potentially leading to postoperative stiffness. This review seeks to academically review and up-to-date literature on this issue, tailored for clinical practice, with the intent of aiding surgeons in staying abreast of this critical subject matter.

Anatomical variants can be used effectively to identify relationships between individuals in kinship analysis and they may be useful during surgical procedures. These procedures can be better implemented when the cause, appearance and location are understood. Clear representations and definitions of anatomical traits are necessary. A similar morphology of pathologies and variations of normal morphology can lead to confusion and unnecessary intervention. Therefore, there is a considerable need for an anatomical atlas of the particular skeletal elements, such as the talus bone. We have analyzed a total of 925 tali, 591 belonging to different modern and pre-Hispanic samples. Furthermore, 334 tali were analyzed from a reference collection from Athens. We have identified and defined the anatomical variants of the talus bone, of which only some have been mentioned by other researchers. We propose standardized methods that may potentially improve future research in human skeleton anatomy and its applications. We provide information on anatomical variants with the aim of improving their identification, classification and use in medical professions and bioanthropology.

Background: Osteoarthritis is caused by damage to the articular cartilage due to bone-on-bone collisions and friction. The length, width, and thickness of the ligaments are expected to change in order to regulate excessive bone-to-bone movement. We aimed to clarify the relationship between ligament morphology and joint surface degeneration in the ankle joints using macroscopic observations and measurements. Methods: The participants were 50 feet of 45 Japanese cadavers. The lengths, widths, and thicknesses of the tibionavicular, tibiospring, tibiocalcaneal, posterior tibiotalar, anterior tibiotalar, and calcaneofibular ligaments (CFLs) were measured. The degeneration of the talonavicular joint surface was investigated macroscopically and classified into two groups: the Degeneration (+) group and Degeneration (-) group. Unpaired t-tests were performed for each measurement. Logistic regression analysis was performed on the significantly different items to obtain cutoff values, sensitivity, and specificity. Results: Only the width of the CFL differed significantly between the Degeneration (+) (20 feet) and Degeneration (-) groups (p < 0.001). In the logistic regression analysis, the width of the CFL had an R2 of 0.262, sensitivity of 75.0%, and specificity of 83.3%, with a cutoff value of 8.7 mm. Conclusions: A wide CFL indicates a high likelihood of talonavicular articular surface degeneration.

The calcaneofibular ligament, a component of the lateral ligament complex of the ankle joint, plays an essential role in ankle-joint stability. To understand the mechanism of sprain-induced calcaneofibular ligament injury, the effect of ankle positions on calcaneofibular ligament tension needs to be ascertained.

We propose a convenient method that combines stretchable strain sensors and an inertial measurement unit for simulative tension analysis of the calcaneofibular ligament in formalin-fixed cadavers. The stretchable strain sensor was pre-stretched approximately 1.3 times and, then set along the direction of the calcaneofibular ligament; a capacitance value from the sensor was used as a parameter to reflect the tension generated. Accurate three-axial inertial measurement unit-based monitoring of joint angles was undertaken for ten cadaveric ankles in measurements at 10° intervals from 30° plantarflexion to 20° dorsiflexion, followed by the investigation of additional effects with 10° inversion and eversion.

Two-way repeated-measures ANOVA revealed a significant interactive effect for plantar/dorsiflexion × inversion/eversion and main effects for plantar/dorsiflexion and inversion/eversion. Post hoc pairwise analysis confirmed that 20° dorsiflexion or 10° inversion induces tension, whereas 10° eversion causes relaxation. Moreover, a promotional interactive effect by 20° dorsiflexion and 10° inversion and an offsetting effect by 10° eversion to 20° dorsiflexion were revealed. The measured values showed high levels of reliability and reproducibility (intraclass correlation coefficient [1,1] = 0.89).

These results appropriately demonstrate the tensile action of calcaneofibular ligament. The novel approach investigated herein potentially opens new avenues for precise ligament-function evaluation.

When the intermediate or collicular fascicle of the medial collateral ligament (MCL) is injured, the diagnosis of posttraumatic medial ankle instability (MAI) is supported. The aim of this study was to describe an arthroscopic all-inside MCL repair after posttraumatic MAI secondary to an isolated injury of the MCL deep fascicle with a knotless suture anchor technique.

Seven patients (seven men, median age: 23 [19-28] years) with posttraumatic MAI were treated by arthroscopic means after failing nonoperative management. The median follow-up was 34 (13-75) months. The MCL was repaired with an arthroscopic all-inside technique.

A tear affecting the deep and intermediate or collicular fascicle of the MCL was observed in all cases. In addition, five patients were diagnosed with an isolated fibular anterior talofibular ligament (ATFL) detachment, and in two patients, both the ATFL and calcaneofibular ligament were involved. All patients reported subjective improvement after the arthroscopic ligament repair. The median American Orthopedic Foot and Ankle Society score increased from 68 (range: 64-70) preoperatively to 100 (range: 90-100) at final follow-up.

Posttraumatic MAI can be successfully treated by an arthroscopic all-inside repair of the MCL. The presence of an MCL tear affecting the tibiotalar ligament fibres attached to the area of the anterior colliculus should be considered a sign of posttraumatic MAI. This partial deltoid injury at the level of the intermediate or collicular fascicle will conduct to a dynamic MAI.

Level IV.

In the treatment of chronic lateral ankle instability (CLAI), the repair of the calcaneofibular ligament (CFL) and anterior talofibular ligament (ATFL) is still being discussed, possibly due to the difficulty in assessing CFL injuries. In particular, it is challenging to evaluate the extent of CFL deficiency quantitively. We hypothesized that CFL tension change would alter morphology of the CFL on magnetic resonance imaging (MRI) and that measuring this morphological change allows assessing CFL injury quantitatively. Thus, this study aimed to analyze the feasibility of quantitatively assessing CFL injuries using MRI.

Sixty-four ankles with CLAI were included and divided into two groups: with (ATFL and CFL group, 31 ankles) or without CFL repair (ATFL group, 33 ankles) in addition to arthroscopic ATFL repair. The angle between the CFL and calcaneal axis (CFLCA) and the bending angles of the CFL was defined as the flexed CFL angle (FCA) were measured on the oblique CFL view of preoperative MRI. The diagnostic abilities of these angles for CFL injury and correlations between these angles and stress radiographs were analyzed.

The sensitivity and specificity of CFLCA were 86.7 % and 88.7 %, and those of FCA were 63.3 % and 77.4 %, respectively. The combination of CFLCA and FCA improved the sensitivity to 93.3 %. The cutoff points of CFLCA and FCA were 3.8° and 121.2°, respectively. There were significant moderate and weak correlations between the talar tilting angle and CFLCA or FCA (rs = -0.533, and rs = -0.402, respectively). The CFLCA and FCA were significantly smaller in the ATFL and CFL group than those in the other groups.

Measurement of CFLCA and FCA in oblique CFL view on MRI could be useful for the quantitative evaluation of CFL injury in patients with CLAI． LEVEL OF EVIDENCE: Level IV. case-control study.

To investigate the prevalence, risk factors, and impact of physiotherapy on ankle sprain recurrence among professional and amateur athletes in the West region of Cameroon.

Cross-sectional study from February to July 2024 in the West region of Cameroon sports clubs. Professional and amateur athletes practice their sport at least three times a week. The main outcomes are reported as the prevalence of the first ankle sprain, the prevalence of recurrence, and the factors associated with recurrence (bivariate analysis, significance set at P<0.05; 95% CI).

 Among the 215 participants, the prevalence of first ankle sprain was 72.6% (156). Of these 156 athletes, only 70 received physiotherapy (44.9%) and only 56 athletes had functional recovery before restarting sport (35.9%). The main barrier to physiotherapy intervention was the lack of knowledge. The prevalence of recurrence was 61.5% (96/156), with significant associations found between recurrence and professional athlete status (aOR: 2.48; CI: 1.09-4.29; P<0.001) and hand-on-ball sports participation (aOR: 4.72; CI: 1.08-29.62; p=0.04). Conversely, physiotherapy intervention (aOR: 0.65; CI: 0.26-0. 98; p=0.01), functional recovery before return to play (aOR: 0.41; CI: 0.05-0.84; p<0.001), and moderate sports frequency (aOR: 0.81; CI: 0.28-0.91; p=0.03) demonstrated protective effects against recurrence.

Education and awareness campaigns are necessary to promote physiotherapy intervention and reduce the burden of ankle sprain recurrence among athletes in Cameroon and Sub-Saharan Africa.

Up to now, there is no convincing evidence, that surgical treatment of deltoid ligament injuries, especially in the setting of ankle fractures, does result in improved outcome. One reason could be a missing diagnostic standard. The aim of the current systematic review was to analyze the applied diagnostic strategies for acute deltoid ligament injuries in outcome studies.

MEDLINE, Scopus, Central, and EMBASE were searched through February 2022 for any original studies addressing diagnostics of acute deltoid injuries. The study was conducted per the PRISMA guidelines. The inclusion criteria were formed according to the PICOS criteria. The data assessed were study type, level of evidence, included fractures, time point and method of diagnosing deltoid ligament layers, differentiation between layers and syndesmotic injuries.

31 studies were included in the final analysis. Most studies (n = 28) based their decision to treat the deltoid ligament injury on radiologic findings only, with stressed radiographs (n = 18) being the most common. The radiographs were applied at one or more time points (preoperative, before ORIF, after ORIF, after ORIF and syndesmotic repair). The most frequently assessed parameter was the Medial Clear Space (MCS, n = 27) with cut-off-values considered pathological ranging between MCS > 1 mm and MCS > 6 mm.

Comparing the 31 studies shows that a standardized method to diagnose deltoid ligament injuries is missing. Further research is needed to establish evidence-based guidelines on how to diagnose acute deltoid ligament injuries.

Prospero ID: CRD42022307112.

not applicable.

Whether the lateral ankle ligaments contribute to syndesmotic stability is still controversial and has been the subject of frequent research recently. In our study, we tried to elucidate this situation using the finite element analysis method. Intact model and thirteen different injury models were created to simulate injuries of the lateral ankle ligaments (ATFL, CFL, PTFL), injuries of the syndesmotic ligaments (AITFL, IOL, PITFL) and their combined injuries. The models were compared in terms of LFT, PFT and EFR. It was observed that 0.537 mm LFT, 0.626 mm PFT and 1.25° EFR occurred in the intact model (M#1), 0.539 mm LFT, 0.761 mm PFT and 2.31° EFR occurred in the isolated ATFL injury (M#2), 0.547 mm LFT, 0.791 mm PFT and 2.50° EFR occurred in the isolated AITFL injury (M#8). The LFT, PFT and EFR amounts were higher in the both M#2 and M#8 compared to the M#1. LFT, PFT and EFR amounts in M#2 and M#8 were found to be extremely close. In terms of LFT and PFT, when we compare models with (LFT: 0.650 mm, PFT: 1.104) and without (LFT: 0.457 mm, PFT: 1.150) IOL injury, it is seen that the amount of LFT increases and the amount of PFT decreases with IOL injury. We also observed that injuries to the CFL, PTFL and PITFL did not cause significant changes in fibular translations and PFT and EFR values show an almost linear correlation. Our results suggest that ATFL injury plays a crucial role in syndesmotic stability.

In sports dance events, athletes often face the risk of ankle injury and instability, which may have a negative impact on their training and athletic performance, and even hinder their rehabilitation process and increase the likelihood of re-injury.

This study aims to observe the effects of exercise intervention (low-load ankle muscle strength training with blood flow restriction training (BFRT) equipment and balance training with blood flow restriction training equipment) combined with instrumentation therapy (Instrument-assisted soft tissue mobilization, IASTM) on ankle function, joint range of motion, and strength in sports dancers with chronic ankle instability (CAI). This study aims to provide an evidence-based approach to rehabilitation for athletes by comparing the effects of combination therapy approaches to traditional ankle strength and stability training.

Forty-two subjects with ankle instability, restriction, or discomfort were selected as observation objects and randomly divided into three groups: the combined group (n = 14, blood flow restriction training combined with IASTM), the simple blood flow restriction training group (n = 15), and the conventional ankle strength and stability training group (n = 13). The intervention lasted for 6 weeks, once a week. The three groups were assessed with the Cumberland ankle instability assessment, Foot and Ankle Ability Measure (FAAM) ankle function assessment score, and ankle range of motion measurement before intervention, after the first intervention, and after 6 weeks of intervention. The ankle strength test was compared and analyzed only before and after intervention.

There was no significant difference in the participant characteristics of the three intervention groups. In terms of Cumberland Ankle Instability Tool (CAIT) scores, within-group comparisons showed that the scores after the first intervention and at the 6-week mark were significantly higher than before the intervention (P < 0.05). Between-group comparisons revealed that the combined intervention group had higher CAIT scores than the other two groups after the 6-week intervention. Regarding the FAAM functional scores, all three interventions significantly improved ankle joint function in patients with chronic ankle instability (P < 0.05), with the BFRT group showing significantly higher FAAM - Activities of Daily Living scale (FAAM-ADL) scores than the control group (P < 0.05). Both the combined and BFRT groups also had significantly higher FAAM-SPORT scores after the first intervention compared to the control (P < 0.05). In terms of ankle range of motion improvement, the combined intervention group showed a significant increase in ankle joint motion after the intervention (P < 0.05), particularly in the improvement of dorsiflexion ability (P < 0.05). As for ankle strength enhancement, all three intervention groups experienced an increase in ankle strength after the intervention (P < 0.05), with the combined intervention group showing a significant improvement in both dorsiflexion and inversion strength compared to the control group (P < 0.05).

BFRT combined with IASTM, isolated BFRT, and conventional ankle strength and stability training significantly improve stability, functionality, and strength in CAI patients. The combined intervention demonstrates superior efficacy in improving ankle range of motion compared to isolated BFRT and conventional approaches.

Syndesmotic ankle fractures occur when there is damage to the syndesmosis complex, resulting in severe pain and instability. Treatment methods include static fixation, dynamic fixation, and fibular nailing. This systematic review and meta-analysis aims to compare the outcomes of these surgical interventions for syndesmotic ankle fractures.

PubMed and Embase were searched up until April 2024 for comparison studies that included at least two of the treatment methods and relevant functional outcomes and complication metrics. Review Manager 5.4 was used for statistical analyses, and a P value ≤0.05 was considered statistically significant. Risk of bias was assessed with Review Manager 5.4. and the Newcastle-Ottawa scale.

Nineteen studies with a total of 1,182 patients met the inclusion criteria. Compared to static fixation, dynamic fixation had a significantly higher Olerud-Molander Ankle Score (OMAS) at both 1-year [standardized mean difference (SMD) =0.43; 95% confidence interval (CI): 0.22 to 0.65; P<0.05] and 2-year post-operation (SMD =0.76; 95% CI: 0.33 to 1.20; P<0.05). Dynamic fixation had a significantly lower reoperation rate than static fixation [risk ratio (RR) =0.55; 95% CI: 0.36 to 0.83; P=0.004]. Compared to static fixation, fibular nail had a significantly higher OMAS at 1-year post-operation (SMD =0.28; 95% CI: 0.03 to 0.53; P=0.03). Fibular nails had significantly lower infection (RR =0.12; 95% CI: 0.04 to 0.37; P<0.05) and reoperation rates (RR =0.22; 95% CI: 0.06 to 0.86; P=0.03) than static fixation. Compared to fibular nail, dynamic fixation had a significantly higher OMAS at both 1-year (SMD =1.07; 95% CI: 0.83 to 1.31; P<0.05) and 2-year post-operation (SMD =1.03; 95% CI: 0.60 to 1.47; P<0.05). Dynamic fixation had a significantly higher reoperation rate compared to fibular nail (RR =20.41; 95% CI: 2.81 to 148.21; P=0.003).

Dynamic fixation seems to be the superior treatment method, displaying better outcomes than static fixation and fibular nailing, with the fibular nail proving to be a viable alternative. Dynamic fixation should be the first choice of treatment for those with syndesmotic ankle fractures due to its clinical advantages compared to static fixation and fibular nailing.

3.

Supramalleolar osteotomy (SMO) is a representative procedure to restore a malalignment in the varus ankle deformity by shifting the concentrated pressure on the medial ankle joint to the lateral area. Additionally, fibula osteotomy (FO) is selectively selected and performed according to the surgeon's preference. However, it is controversial whether FO is effective in shifting the abnormal pressure from the medial to the lateral area on the ankle joint. Some cadaveric studies have been performed to prove this. However, it is difficult to consistently reconstruct amount of the varus ankle deformities angle in cadavers and to guarantee reliable contact pressure between the ankle joint. Thus, the aim of this study was predicted and quantitatively compared a peak pressure between single SMO and SMO with FO procedure by using a finite element analysis as a powerful biomechanical tool to those limitations of cadaveric study. This study reconstructed total 4 3D foot and ankle models including a normal and pre-op model and 2 post-op models. The pre-op model was modified by assigning 10° varus tilting corresponding to stage 3b in the classification of varus ankle osteoarthritis based on the validated normal model. Also, the post-op models were reconstructed by applying single SMO and SMO with FO, respectively. All of the models were assumed as one-leg standing position and to mimic smooth ankle joint motion. Peak contact pressure change was predicted at the medial ankle joint by using computational simulation. As a result, 2 post-op models showed a remarkably peak pressure reduction by up to 5.5 times on the medial tibiotalar joint. However, a comparison between single SMO and SMO with FO model showed no appreciable differences. In conclusion, this study predicted that single SMO may be as effective as SMO with FO in reducing peak contact pressure on the medial tibiotalar joint in varus ankle osteoarthritis.

Background Pathologies affecting the ankle joint and hindfoot can present with a variety of clinical symptoms and etiologies, necessitating accurate diagnostic tools for effective management. Magnetic resonance imaging (MRI) is a valuable imaging modality for assessing these pathologies, providing detailed visualization of bone, joint, tendon, and other soft tissue abnormalities. Objectives To evaluate MRI findings in a diverse cohort of 105 participants with pathologies affecting the ankle joint and hindfoot, focusing on the prevalence and types of bone, joint, tendon, and soft tissue abnormalities. Materials and methods A single-center observational descriptive study was conducted at Dr. D. Y. Patil Medical College and Hospital and Research Centre, Pune, India, over a period from August 2022 to July 2024, involving 105 participants (54.3% male, 45.7% female) with a mean age of 39.04 years. MRI scans were analyzed to assess the prevalence of bone, joint, tendon, and soft tissue pathologies. Clinical profiles, symptom duration, and etiological classifications were documented. Results Analysis of the results obtained from 105 (N = 105) study participants revealed that pain (94.3%, or 99 cases) was the most common symptom, followed by restricted movement (86.7%, or 91 cases), trauma history (75.2%, or 79 cases), and swelling (73.3%, or 77 cases). Traumatic causes (76.2%, or 80 cases) predominated, while inflammatory (48.3%, or 14 cases) and infective (34.5%, or 10 cases) causes were also significant. MRI findings showed marrow edema in 41.9%, or 44 cases, subchondral cysts in 22.9% (24 cases), fractures in 17.1% (18 cases), and erosions in 10.5% of participants (11 cases). Joint involvement was most frequent in the tibiotalar (76.2%, or 80 cases) and subtalar joints (58.1%, or 61 cases). Tendon pathologies included peritendonitis (55.2%, or 58 cases) and tendinosis (23.8%, or 25 cases), with the Achilles tendon being the most frequently affected (39%, or 41 cases). Ligament injuries were predominantly sprains (46.7%, or 49 cases), with less frequent partial (18.1%, or 19 cases) and complete tears (7.6%, or eight cases). Soft tissue findings included subcutaneous edema (76.2%, or 80 cases) and bursitis (24.8%, or 26 cases). Among the study participants who presented with non-traumatic pathologies, inflammatory pathologies (48.3%, or 14 cases) were the most common, followed by infective (34.5%, or 10 cases) and neoplastic (17.2%, or five cases) pathologies. Conclusion MRI effectively identifies a wide range of pathologies in the ankle and hindfoot, with marrow edema, joint effusion, and tendon pathologies being prevalent. The study underscores the utility of MRI in diagnosing and assessing various conditions in the ankle joint complex and highlights the need for accurate imaging to guide treatment decisions. Future research should focus on correlating MRI findings with clinical outcomes to enhance diagnostic accuracy and management strategies.

The lateral ankle joint comprises the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL). The purpose of this study was to propose a classification of CFL morphology.

The material comprised 120 paired lower limbs from human cadavers (30 male, 30 female), mean age 62.3 years. The morphology was carefully assessed, and morphometric measurements were performed.

A 4-part method for anatomic classification can be suggested based on our study. Type 1 (48.3%), the most common type, was characterized by a bandlike morphology. Type 2 (9.2%) was characterized by a Y-shaped band, and type 3 (21.7%) by a V-shaped band. Type 4 (20.8%) was characterized by the presence of 2 or 3 bands. Type 2 and 4 were divided into further subtypes based on origin footprint.

The aim of our study was to describe variations of calcaneofibular ligament. Our proposed 4-part classification may be of value in clinical practice in future recognition of CFL injuries and in its repair or reconstruction.

The anatomy of the CFL plays an important role in stability of the ankle. Greater recognition of anatomical variation may help improve reconstructive options for patients with chronic lateral ankle instability.

The majority of patients with an osteochondral lesion of the talus (OLT) report a history of trauma. Therefore, it is important to assess for concomitant ankle instability when dealing with patients with a symptomatic OLT. The History; Alignment; Ligaments; Others "(HALO)" approach can be a helpful tool in the evaluation of patients with an OLT. If conservative treatment fails, surgery may be indicated. Although there is a lack of comparative studies investigating the effect of stabilization procedures on cartilage repair, we believe that addressing instability is a key factor in improving patient outcome.

The talocrural joint and the subtalar joint are the two major joints of the ankle-joint complex. The position and direction of the exosuit force line relative to these two joint axes can influence ankle motion. We aimed to understand the effects of different force-lines on ankle multidimensional motion.

In this article, three assistance force line schemes for ankle exosuits were proposed: perpendicular to the talocrural joint axis (PT), intersecting with the subtalar joint axis (IS), and parallel to the triceps surae (PTS). A theoretical model was proposed to calculate the exosuit's assistance moment. Seven participants completed four experimental tests of ankle plantarflexion, including three passive motions assisted by the PT, PTS and IS schemes, and one active motion without exosuit assistance (Active).

The simulation results demonstrated that all three exosuits were able to produce significant moments of ankle plantarflexion. Among these, the PT scheme exhibited the highest moments in all dimensions, followed by the PTS and IS schemes. The experimental findings confirmed the effectiveness of all three exosuit schemes in assisting ankle plantarflexion. Additionally, as the assistive force lines approached the subtalar joint, there was a decrease in ankle motion assisted by the exosuits in non-plantarflexion directions, along with a reduction in the average distance of ankle angle curves relative to active ankle motion. Furthermore, the linear correlation coefficients between inversion and plantarflexion, adduction and plantarflexion, and adduction and inversion gradually converged toward active ankle plantarflexion motion.

Our research indicates that the position of the exosuit force line to the subtalar joint has a significant impact on ankle inversion and adduction. Among all three schemes, the IS, which has the closest distance to the subtalar joint axes, has the greatest kinematic similarity to active ankle plantarflexion and might be a better choice for ankle assistance and rehabilitation.

The majority of the ankle osteoarthritis cases are posttraumatic and affect younger patients with a longer projected life span. Hence, joint-preserving surgery, such as supramalleolar osteotomy becomes popular among young patients, especially those with asymmetric arthritis due to alignment deformities. However, there is a lack of biomechanical studies on postoperative evaluation of stress at ankle joints. We aimed to construct a verifiable finite element model of the human hindfoot, and to explore the effect of different osteotomy parameters on the treatment of varus ankle arthritis.

The bones of the hindfoot are reconstructed using normal CT tomography data from healthy volunteers, while the cartilages and ligaments are determined from the literature. The finite element calculation results are compared with the weight-bearing CT (WBCT) data to validate the model. By setting different model parameters, such as the osteotomy height (L) and the osteotomy distraction distance (h), the effects of different surgical parameters on the contact stress of the ankle joint surface are compared.

The alignment and the deformation of hindfoot bones as determined by the finite element analysis aligns closely with the data obtained from WBCT. The maximum contact stress of the ankle joint surface calculated by this model increases with the increase of the varus angle. The maximum contact stresses as a function of the L and h of the ankle joint surface are determined.

The relationship between surgical parameters and stress at the ankle joint in our study could further help guiding the planning of the supramalleolar osteotomy according to the varus/valgus alignment of the patients.

An improved understanding of contact mechanics in the ankle joint is paramount for implant design and ankle disorder treatment. However, existing models generally simplify the ankle joint as a revolute joint that cannot predict contact characteristics. The current study aimed to develop a novel musculoskeletal ankle joint model that can predict contact in the ankle joint, together with muscle and joint reaction forces. We modelled the ankle joint as a multi-axial joint and simulated contact mechanics between the tibia, fibula and talus bones in OpenSim. The developed model was validated with results from experimental studies through passive stiffness and contact. Through this, we found a similar ankle moment-rotation relationship and contact pattern between our study and experimental studies. Next, the musculoskeletal ankle joint model was incorporated into a lower body model to simulate gait. The ankle joint contact characteristics, kinematics, and muscle forces were predicted and compared to the literature. Our results revealed a comparable peak contact force and the same muscle activation patterns in four major muscles. Good agreement was also found in ankle dorsi/plantar-flexion and inversion/eversion. Thus, the developed model was able to accurately model the ankle joint and can be used to predict contact characteristics in gait.

Background: Corrective shoe insoles are prescribed for a range of foot deformities and are typically designed based on a subjective assessment limiting personalization and potentially leading to sub optimal treatment outcomes. The incorporation of in silico techniques in the design and customization of insoles may improve personalized correction and hence insole efficiency. Methods: We developed an in silico workflow for insole design and customization using a combination of measured motion capture, inverse musculoskeletal modelling as well as forward simulation approaches to predict the kinematic response to specific insole designs. The developed workflow was tested on twenty-seven participants containing a combination of healthy participants (7) and patients with flatfoot deformity (20). Results: Average error between measured and simulated kinematics were 4.7 ± 3.1, 4.5 ± 3.1, 2.3 ± 2.3, and 2.3 ± 2.7° for the chopart obliquity, chopart anterior-posterior axis, tarsometatarsal first ray, and tarsometatarsal fifth ray joints respectively. Discussion: The developed workflow offers distinct advantages to previous modeling workflows such as speed of use, use of more accessible data, use of only open-source software, and is highly automated. It provides a solid basis for future work on improving predictive accuracy by adapting the currently implemented insole model and incorporating additional data such as plantar pressure.

The increase in ankle sprains in children is a reflection of the greater inclusion of this population in sports. This places the calcaneofibular (CFL) and the anterior talofibular (ATFL) ligaments in focus for study. In adults, the presence of arcuate fibers extending between these two ligaments suggests the existence of a new anatomical and functional complex called the lateral fibulotalocalcaneal ligament of the ankle (LFTCL), which can be associated with the persistence of instability of the talocrural joint in ankle sprains. This study aimed to verify the presence of arciform fibers between the CFL and ATFL in human fetuses and to study the topography of the lateral ankle region.

Forty matched fetal ankles aged between 28 and 38 weeks, fixed in 4% formalin, were macroscopically, chemically and mesoscopically dissected and analyzed in stereoscope.

The ATFL was characterized as a capsular ligament consisting of two fascicles (proximal and distal). The CFL was characterized as an extracapsular ligament. The LFTCL complex was verified in all specimens, characterized by the arcuate fibers between the ATFL and the CFL.

Such results suggest that this functional unit is congenital and that it should be taken into consideration in the treatment of persistent ankle instabilities in the pediatric population.

Evans and Hintermann lateral column lengthening (LCL) procedures are both widely used to correct adult acquired flatfoot deformity (AAFD), and have both shown good clinical results. The aim of this study was to compare these two procedures in terms of corrective ability and biomechanics influence on the Chopart and subtalar joints through finite element (FE) analysis.

Twelve patient-specific FE models were established and validated. The Hintermann osteotomy was performed between the medial and posterior facets of the subtalar joint; while, the Evans osteotomy was performed on the anterior neck of the calcaneus around 10 mm from the calcaneocuboid joint surface. In each procedure, a triangular wedge of varying size was inserted at the lateral edge. The two procedures were then compared based on the measured strains of superomedial calcaneonavicular ligaments and planter facia, the talus-first metatarsal angle, and the contact characteristics of talonavicular, calcaneocuboid and subtalar joints.

The Hintermann procedure achieved a greater correction of the talus-first metatarsal angle than Evans when using grafts of the same size, indicating that Hintermann had stronger corrective ability. However, its distributions of von-Mises stress in the subtalar, talonavicular and calcaneocuboid joints were less homogeneous than those of Evans. In addition, the strains of superomedial calcaneonavicular ligaments and planter facia of Hintermann were also greater than those of Evans, but both generally within the safe range (less than 6%).

This FE analysis study indicates that both Evans and Hintermann procedures have good corrective ability for AAFD. Compared to Evans, Hintermann procedure can provide a stronger corrective effect while causing greater disturbance to the biomechanics of Chopart joints, which may be an important mechanism of arthritis. Nevertheless, it yields a better protection to the subtalar joint than Evans osteotomy.

Both Evans and Hintermann LCL surgeries have a considerable impact on adjacent joints and ligament tissues. Such effects alongside the overcorrection problem should be cautiously considered when choosing the specific surgical method.

Level III, case-control study.

Ankle sprains are prevalent injuries leading to functional impairment. The lateral ankle ligament complex (LLC), comprising the anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), and calcaneofibular ligament (CFL), is weak and prone to injury. The morphometric data of these ligaments are essential for orthopedic practices, including techniques like direct repair or ATFL reconstruction with autograft/allograft, which are limited in the literature. The present study aims to document the anatomy and morphometry of the LLC.

Fifteen adult Indian-origin embalmed cadavers were selected for the study. Ankles with antemortem or postmortem injuries or previous surgical interventions were excluded from the study. After precise dissection of the ankle's anterior and lateral aspects as per Cunningham's dissection manual, ligaments were exposed. Length and width were measured using a digital vernier caliper. Morphological attributes such as shape, orientation, and inter-fiber angles were documented.

The most common shape in ATFL was a single band (53.33%). Inner ATFL fibers merged with the ankle joint capsule in 73.33%. ATFL mean length and width were 14 ± 2.4 mm and 7.6 ± 2.0 mm. The angle between the fibula's long axis and ATFL fibers was 107 ± 22°, and the angle between tibiotalar joint lines and parallel ATFL fibers was 30 ± 9.5°. A single band of CFL was predominant (73.33%). The mean length and width of CFL were 18.4 ± 3.9 mm and 5.2 ± 1.3 mm; the angle between the anterior fibula border's long axes and parallel CFL line was 131°. PTFL length was 20.9 ± 3.3 mm and width was 6.2 ± 1.4 mm. The mean length and width of the anterior inferior talofibular ligament (AiTFL) were 11.7 ± 2.6 mm and 9.5 ± 1.6 mm, and of the posterior inferior talofibular ligament (PiTFL) were 12.8 ± 2.1 mm and 10.4 ± 2 mm.

Comprehensive knowledge of these ligaments' anatomy and relationships is vital for clinical examination and ultrasonography. Understanding LLC details aids radiologists and orthopedic surgeons in graft selection, sizing, and precise anatomical structure placement during surgical reconstruction.

The aim was to provide an update on anatomy and function of the medial ankle ligaments, diagnosis of their injuries and treatment of medial ankle instability.

Literature search on PubMed.

Injuries to the deltoid ligament are not uncommon in relation to malleolar fractures and ankle sprains. Chronic instability may lead to ankle osteoarthritis. However, there is no consensus on diagnostic criteria (clinically, by imaging and by arthroscopy), on indications for non-operative and operative treatment, and on standards for repair and reconstruction of the ligament complex. There is no current evidence to support acute repair of deltoid ligament injury. Reports on the effect of isolated deltoid ligament reconstruction are very sparse.

There is a need for a focused effort to establish evidence for all aspects of deltoid ligament injury.

Arthroscopic anterior talofibular ligament (ATFL) repair for chronic lateral ankle instability (CLAI) has been widely performed. The recurrence of the instability after the surgery sometimes occurs, which may cause the development of osteoarthritis. Therefore, it is important to elucidate the factors of the recurrence. This study aimed to evaluate the loosening of the capsule in the MRI and whether it affected clinical outcomes or not in arthroscopic ATFL repair.

Thirty-eight ankles in 35 patients with CLAI treated by arthroscopic lateral ligament repair were included. The capsule protrusion area defined as the area that protruded ATFL laterally from the line connecting the fibula and talus attachment on MRI was measured. Capsule protrusion area in ankles with or without CLAI was compared and the relationships between it and clinical outcomes were assessed.

The capsule protrusion area in the CLAI group (74.2 ± 36.4 mm2) was significantly larger than that in the control (25.5 ± 14.3 mm2) (p < 0.01). The capsule protrusion area in the poor remnant group (93.8 ± 36.4 mm2) was significantly larger than that in the excellent (53.2 ± 40.3 mm2) (p < 0.05). The capsule protrusion area in the patients with recurrent instability (99.8 ± 35.2 mm2) was significantly larger than that without recurrent instability (62.4 ± 30.9 mm2) (p < 0.01). Clinical scores in the recurrent group were significantly lower than those in the non-recurrent group (p < 0.05).

Capsule loosening would be one of the causes of the recurrence of instability after arthroscopic lateral ankle ligament repair. Evaluation of the capsule protrusion area on MRI is helpful to choose appropriate surgical procedures for CLAI patients.

The functional role of the calcaneofibular ligament (CFL) is still controversial. We aimed to investigate the anatomical features of the CFL on sonography and the elastic modulus of the CFL in different ankle positions using ultrasound shear-wave elastography (SWE).

In 14 cadaveric ankles, the angle of the CFL with respect to the long axis of the fibula was measured in the following ankle positions: neutral (N), 30° plantar flexion (PF), and 20° dorsiflexion (DF). In addition, in 24 ankles of healthy adult volunteers, the elastic modulus of the CFL was evaluated with ultrasound SWE in the following ankle positions: neutral (N), 30° plantar flexion with inversion (PI), 30° plantar flexion with eversion (PE), 20° dorsiflexion with inversion (DI), and 20° dorsiflexion with eversion (DE).

The mean angle of the CFL in N, PF, and DF positions was 139.9° ± 12.7°, 121.3° ± 14.1°, and 158.6° ± 13.1°, respectively. The angle of the CFL in N was significantly greater than that in PF and smaller than that in DF (P < 0.0001, both). The mean elastic modulus of the CFL in the N, PI, PE, DI, and DE positions was: 63.6 ± 50.8, 148.0 ± 39.4, 75.8 ± 40.6, 88.1 ± 31.6, and 61.7 ± 29.4 kPa, respectively. The elastic modulus in PI was significantly higher than in other positions, while the values obtained in DI and DE were also significantly different (P < 0.001, both).

The angle of the CFL increased with DF. Moreover, ultrasound SWE showed that the CFL was tensed and likely to be injured in the PI position.

Lateral ankle sprains and instability are an increasingly identified pain point for patients, accounting for 20 to 25% of musculoskeletal injuries. Lateral ankle injuries are especially concerning given the propensity for patients to develop chronic lateral ankle instability and for the high risk of reinjury on an unstable ankle. With the complex articulation of the tibiofibular syndesmosis, subtalar, and talocrural joints, pinpointing ankle dysfunction remains difficult. Multiple reviews have evaluated management and diagnosis of lateral ankle instability, but with newer treatment options available, a more comprehensive assessment of the current literature was conducted. Although multiple surgical options exist, many nonsurgical functional options have also been developed for patients that may help patients prevent the development of chronic lateral ankle instability. In recent times, many new options have come up, including in-office needle arthroscopy and continual advancements in diagnosis and our understanding of this difficult topic. Multiple reviews have evaluated the management and diagnosis of lateral ankle instability, but with newer treatment options available, a more comprehensive assessment of the current literature was conducted. Given this, this review will help to highlight new diagnostic and nonsurgical therapeutic options for the management of lateral ankle instability.

Preservation of syndesmotic ligaments is crucial for preventing adverse sequelae at the donor site following free fibula osteocutaneous flap harvesting. This study sought to determine the relationship between distal tibiofibular ligaments and the fibular segment to identify radiological landmarks that facilitate safe and precise flap. The distances between the distal tibiofibular ligaments (anterior inferior tibiofibular ligament [AITFL], posterior inferior tibiofibular ligament [PITFL]) and the fibular segment, as well as the lower border of the interosseous membrane, were measured on magnetic resonance imaging (MRI) scans of 296 patients without any perceivable ankle abnormalities. The mean distances (± SD) between the distal end of the fibula and the AITFL, PITFL, and lower interosseous membrane border were 3.0 ± 0.4 cm, 2.6 ± 0.4 cm, and 3.9 ± 0.6 cm, respectively. The distance between the talar dome and the PITFL exhibited a range of 0.0-0.5 cm. Our findings support preserving a distal fibular remnant of at least 4 cm to avoid injury to the syndesmotic ligament throughout fibula osteocutaneous flap harvesting. The talar dome could serve as a useful radiological landmark for identifying the upper border of PITFL during preoperative evaluation, and thus facilitating precise and safe flap procurement.