Search

Abstract Background There is still some controversy about the augmentation of the inferior extensor retinaculum after arthroscopic anterior talofibular ligament repair. The aim of this study was to evaluate the novel arthro-Broström procedure with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques for chronic lateral ankle instability. Methods Thirty-four cases with grade-2 or grade-3 chronic anterior talofibular ligament lesions who underwent the novel arthro-Broström procedure with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques were assessed retrospectively. A total of 30 cases (30 ankles) were followed up for a mean of 26.67 ± 4.19 months (range, 24—36 months). four cases were excluded due to insufficient medical records or loss of follow-up reports. The Cumberland Ankle Instability Tool scores, The Karlsson-Peterson scores and Visual Analogue Scale scores were evaluated before surgery and at the final follow-up time. Also, the results of stress fluoroscopic tests and complications were recorded. Results At the final follow-up, the average of the Cumberland Ankle Instability Tool scores, The Karlsson-Peterson scores and Visual Analogue Scale scores were 86.63 ± 6.69 (range, 77—100), 90.17 ± 4.64 (range, 85—100) and 0.53 ± 0.63 (range, 0—2), respectively. Moreover, the results of stress fluoroscopic tests were improved significantly after surgery. Mild keloid formation and/or knot irritation were observed in four cases. No wound infections, nerve injuries and recurrent instability were recorded. Also, no stiffness or arthritis of the subtalar joint was encountered. Conclusions The arthro-Broström procedure combined with endoscopic retinaculum augmentation using all-inside lasso-loop techniques is reliable and safe due to the advantage of direct endoscopic visualization.

Abstract Objective To specify indications and contraindications of the modified percutaneous inferior extensor retinaculum augmentation (PIERA) technique for chronic ankle instability cases, and to introduce technique details and report surgical outcomes and complications. Methods The PIERA technique was performed on seven patients with chronic ankle instability (four females and three males, 36.4 ± 15.1 years of age, and course of symptoms of 33.7 ± 8.8 months) from June to October 2018 in this retrospective study of case series. All patients demonstrated attenuated ligamentous tissue quality, which was confirmed using preoperative ankle MRI. IER were drew up to the distal fibula using suture anchors with the ankle in neutral position for all cases, to engage the entire IER in reconstructing the stability of the ankle. Patients were assessed using American Orthopaedic Foot and Ankle Society Ankle‐Hindfoot (AOFAS) score and Cumberland Ankle Instability Tool (CAIT) scores pre‐ and postoperatively at the last follow‐up examination. Preoperative and postoperative outcome scores of patients were compared using paired t‐test. A p value of less than 0.05 was regarded statistically significant. Results Mean follow‐up duration was 16.7 ± 1.6 months. The mean AOFAS score significantly improved from 66.9 ± 11.2 preoperatively to 93.7 ± 8.5 postoperatively (P = 0.001). Mean CAIT score significantly improved from 13.1 ± 4.7 preoperatively to 26.3 ± 1.8 postoperatively (P = 0.001). Patients did not report any wound healing problem, numbness, swelling, or instability at the last follow‐up examination, except for one patient who reported pain and minimal stiffness, and presented an AOFAS score of less than 80 and a CAIT score below 24. All patients returned to at least recreational sport activity level. Conclusion The PIERA technique can improve the functional outcomes of patients with chronic ankle instability with few complications.

Abstract Purpose The Brostrom-Gould procedure is currently the gold standard surgical choice for the treatment of chronic ankle instability; it can significantly improve ankle function and stability in patients. However, recent studies have reported doubts regarding the feasibility of the inferior extensor retinaculum (IER) after Brostrom-Gould and therapeutic effects compared with the Brostrom procedure. The purpose of the present study was to observe the anatomical characteristics of the lateral part of the IER using cadaveric bodies in order to guide the surgical operation of chronic ankle instability. Methods Twenty-three cadaveric ankles were dissected. The morphology of the IER and its internal structure was observed and recorded for each ankle. The shortest distance between the Stem ligament of the IER and the anterior fibular periosteum (AFP) was measured and recorded, then attempts were made to suture the Stem to the AFP. Results Twelve of the cadaveric ankles were observed as having an oblique superolateral band (OSLB) that had a tough texture upward of the lateral IER connecting with SL, as are the characteristics of the oblique superolateral band (OSLB) reported in previous studies. The inner and outer membrane of the OSLB were connected with inner and outer membrane of Stem. The average value of the distance between the Stem and AFP was 11.60 ± 2.71 mm, and the maximum and the minimum distance were 19.04 mm and 6.53 mm, respectively. The P -value (P = 0.2) resulting from a single sample K-S test confirmed that the distribution of distances conformed to normality. None of the SL in the study could be sutured to the AFP. Conclusion The OSLB of the IER has a tough texture and connects with the Stem, and has the potential be utilised in the Brostrom-Gould procedure. However, we do not recommend utilization of the Stem in this operation regardless of the distance between the AFP and the Stem. When the Stem cannot be used to enhance repair in this operation, other solutions can be used for strengthening and to protect the repaired ATFL.

Localisation and injection of the sinus tarsi can be challenging, particularly for the less experienced musculoskeletal sonographer/practitioner. The inferior extensor retinaculum arises from the sinus tarsi in the form of three roots (medial, intermediate and lateral) which are collectively termed the frondiform ligament. This is readily identified on ultrasound and can be used as a reference point to aid the safe delivery of injectate material into the sinus tarsi. This article describes the technique and its anatomical basis. [ABSTRACT FROM AUTHOR]

Background: There is still some controversy about the augmentation of the inferior extensor retinaculum after arthroscopic anterior talofibular ligament repair. The aim of this study was to evaluate the novel arthro-Broström procedure with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques for chronic lateral ankle instability.Methods: Thirty-four cases with grade-2 or grade-3 chronic anterior talofibular ligament lesions who underwent the novel arthro-Broström procedure with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques were assessed retrospectively. A total of 30 cases (30 ankles) were followed up for a mean of 26.67 ± 4.19 months (range, 24-36 months). four cases were excluded due to insufficient medical records or loss of follow-up reports. The Cumberland Ankle Instability Tool scores, The Karlsson-Peterson scores and Visual Analogue Scale scores were evaluated before surgery and at the final follow-up time. Also, the results of stress fluoroscopic tests and complications were recorded.Results: At the final follow-up, the average of the Cumberland Ankle Instability Tool scores, The Karlsson-Peterson scores and Visual Analogue Scale scores were 86.63 ± 6.69 (range, 77-100), 90.17 ± 4.64 (range, 85-100) and 0.53 ± 0.63 (range, 0-2), respectively. Moreover, the results of stress fluoroscopic tests were improved significantly after surgery. Mild keloid formation and/or knot irritation were observed in four cases. No wound infections, nerve injuries and recurrent instability were recorded. Also, no stiffness or arthritis of the subtalar joint was encountered.Conclusions: The arthro-Broström procedure combined with endoscopic retinaculum augmentation using all-inside lasso-loop techniques is reliable and safe due to the advantage of direct endoscopic visualization. [ABSTRACT FROM AUTHOR]

This study investigated the frequency and types of 1) orientation of the deep peroneal nerve (DPN) and its branches relative to the dorsalis pedis artery (DPA) and the extensor hallucis longus tendon (EHLT) and 2) branching site and pattern of DPN at the distal area of leg and the proximal zone of the foot. One-hundred and sixty specimens from the lower extremities of 80 formalin-embalmed cadavers were investigated for anatomical position, orientation and the branching pattern of DPN by manual dissection, starting from the anterior side of lower extremity just proximal to ankle joint down to the area distal to inferior extensor retinaculum. The most prevalent medial-to-lateral orientation of structures in the area anterior to ankle joints was the EHLT/DPA/DPN. Comparing DPA with the branching of DPN in the areas inside anterior tarsal tunnel (ATT) and distal to ATT, the most common type was an orientation of DPA that was lateral to both the DPN main trunk and its medial terminal branch. Regarding branching sites and patterns of DPN in the intermalleolar and ATT areas, nearly half of the studied specimens had DPN bifurcation at the intermalleolar level and more than half of the bifurcations were inside the ATT. This study establishes novel data regarding type variation and prevalence of DPN in areas of ankle and proximal part of foot in the Thai population which could be helpful in clinical practice. [ABSTRACT FROM AUTHOR]

Objective: To specify indications and contraindications of the modified percutaneous inferior extensor retinaculum augmentation (PIERA) technique for chronic ankle instability cases, and to introduce technique details and report surgical outcomes and complications. Methods: The PIERA technique was performed on seven patients with chronic ankle instability (four females and three males, 36.4 ± 15.1 years of age, and course of symptoms of 33.7 ± 8.8 months) from June to October 2018 in this retrospective study of case series. All patients demonstrated attenuated ligamentous tissue quality, which was confirmed using preoperative ankle MRI. IER were drew up to the distal fibula using suture anchors with the ankle in neutral position for all cases, to engage the entire IER in reconstructing the stability of the ankle. Patients were assessed using American Orthopaedic Foot and Ankle Society Ankle‐Hindfoot (AOFAS) score and Cumberland Ankle Instability Tool (CAIT) scores pre‐ and postoperatively at the last follow‐up examination. Preoperative and postoperative outcome scores of patients were compared using paired t‐test. A p value of less than 0.05 was regarded statistically significant. Results: Mean follow‐up duration was 16.7 ± 1.6 months. The mean AOFAS score significantly improved from 66.9 ± 11.2 preoperatively to 93.7 ± 8.5 postoperatively (P = 0.001). Mean CAIT score significantly improved from 13.1 ± 4.7 preoperatively to 26.3 ± 1.8 postoperatively (P = 0.001). Patients did not report any wound healing problem, numbness, swelling, or instability at the last follow‐up examination, except for one patient who reported pain and minimal stiffness, and presented an AOFAS score of less than 80 and a CAIT score below 24. All patients returned to at least recreational sport activity level. Conclusion: The PIERA technique can improve the functional outcomes of patients with chronic ankle instability with few complications. [ABSTRACT FROM AUTHOR]

Purpose: The Brostrom-Gould procedure is currently the gold standard surgical choice for the treatment of chronic ankle instability; it can significantly improve ankle function and stability in patients. However, recent studies have reported doubts regarding the feasibility of the inferior extensor retinaculum (IER) after Brostrom-Gould and therapeutic effects compared with the Brostrom procedure. The purpose of the present study was to observe the anatomical characteristics of the lateral part of the IER using cadaveric bodies in order to guide the surgical operation of chronic ankle instability.Methods: Twenty-three cadaveric ankles were dissected. The morphology of the IER and its internal structure was observed and recorded for each ankle. The shortest distance between the Stem ligament of the IER and the anterior fibular periosteum (AFP) was measured and recorded, then attempts were made to suture the Stem to the AFP.Results: Twelve of the cadaveric ankles were observed as having an oblique superolateral band (OSLB) that had a tough texture upward of the lateral IER connecting with SL, as are the characteristics of the oblique superolateral band (OSLB) reported in previous studies. The inner and outer membrane of the OSLB were connected with inner and outer membrane of Stem. The average value of the distance between the Stem and AFP was 11.60 ± 2.71 mm, and the maximum and the minimum distance were 19.04 mm and 6.53 mm, respectively. The P -value (P = 0.2) resulting from a single sample K-S test confirmed that the distribution of distances conformed to normality. None of the SL in the study could be sutured to the AFP.Conclusion: The OSLB of the IER has a tough texture and connects with the Stem, and has the potential be utilised in the Brostrom-Gould procedure. However, we do not recommend utilization of the Stem in this operation regardless of the distance between the AFP and the Stem. When the Stem cannot be used to enhance repair in this operation, other solutions can be used for strengthening and to protect the repaired ATFL. [ABSTRACT FROM AUTHOR]

Background: Although several arthroscopic surgical techniques for the treatment of chronic ankle instability (CAI) have been introduced recently, the effect of inferior extensor retinaculum (IER) augmentation remains unclear. Purpose: To compare the clinical outcomes after arthroscopic anterior talofibular ligament (ATFL) repair according to whether additional IER augmentation was performed or not. Study Design: Cohort study; Level of evidence, 3. Methods: We performed a retrospective review of consecutive patients who underwent arthroscopic ATFL repair surgery for CAI between 2016 and 2018. The mean age of the patients was 35.2 years (range, 19-51 years), and the mean follow-up period was 32.6 months (range, 24-48 months). Patients were divided into 2 groups according to the surgical technique used for CAI: arthroscopic ATFL repair (group A; n = 37) and arthroscopic ATFL repair with additional IER augmentation (group R; n = 45). The pain visual analog scale, American Orthopaedic Foot & Ankle Society score, Foot and Ankle Outcome Score, and the Karlsson Ankle Function Score were measured as subjective outcomes, and posturographic analysis was performed using a Tetrax device as an objective outcome. Radiologic outcome evaluations were performed preoperatively and at 2 years postoperatively using stress radiographs and axial view magnetic resonance imaging (MRI). Results: Out of 101 patients, 19 (18.5%) were excluded per the exclusion criteria, and 82 were evaluated. We identified 6 retears (7.3%) based on postoperative MRI evaluation. All patients who had ATFL retear on MRI (8.1% [3/37] in group A and 6.7% [3/45] in group R) demonstrated recurrent CAI with functional discomfort and anterior displacement >3 mm as compared with the intact contralateral ankle. All clinical scores and posturography results were improved after surgery in both groups (P <.001). However, there were no significant differences in the clinical results and radiologic findings between the groups. Conclusion: The clinical and radiologic outcomes of patients with CAI improved after all-inside arthroscopic ATFL repair. However, additional IER augmentation after arthroscopic ATFL repair did not guarantee better clinical outcomes. [ABSTRACT FROM AUTHOR]

Ligament injuries around the subtalar, talocalcaneonavicular, and calcaneocuboid joints are often underestimated on clinical and imaging findings during investigation of patients with ankle and foot injuries. Because a delayed diagnosis of midtarsal ligament tears may lead to chronic pain and functional disability, an in-depth knowledge of the complex regional anatomy and of the appropriate ultrasound scanning technique is a prerequisite for evaluating these structures and avoiding misdiagnoses. The objective of this article is twofold: to describe the relevant anatomy and biomechanics related to the ligaments that stabilize the subtalar, talocalcaneonavicular, and calcaneocuboid joints, and to illustrate reasoned landmark-based scanning techniques to provide a systematic examination of these ligaments and thus make ultrasound an effective tool for assessment of patients with suspected subtalar or midtarsal sprain. [ABSTRACT FROM AUTHOR]

Purpose: The open "Broström-Gould" procedure has become the gold standard technique for the treatment of chronic ankle instability. Although arthroscopic techniques treating ankle instability have significantly evolved in the last years, no all arthroscopic Broström-Gould has been described. The aim of the study was to describe the all-arthroscopic Broström-Gould technique [anterior talofibular ligament (ATFL) repair with biological augmentation using the inferior extensor retinaculum (IER)], and to evaluate the clinical results in a group of patients.Methods: Fifty-five patients with isolated lateral ankle instability were arthroscopically treated. Arthroscopic ATFL repair with biological augmentation was performed through a two-step procedure. First, the ligament is reattached through an arthroscopic procedure. Next, the ligament is augmented with the IER that is endoscopically grasped. Both the ligament repair and its augmentation with IER were performed with the help of an automatic suture passer and two soft anchors. Characteristics of the patients, and pre- and postoperatively AOFAS and Karlsson scores were recorded.Results: The median preoperative AOFAS score increased from 74 (range 48-84) to 90 (range 63-100). According to the Karlsson score, the median preoperative average increased from 65 (range 42-82) to 95 (range 65-100). No major complications were reported. Only one case (1.8%) required a revision surgery at 23 months of follow-up.Conclusion: The arthroscopic all-inside ATFL repair with biological augmentation using the IER is a reproducible technique. Excellent clinical results were obtained. The technique has the advantage of its minimally invasive approach and the potential to treat concomitant ankle intra-articular pathology.Level Of Evidence: Retrospective case series, Level IV. [ABSTRACT FROM AUTHOR]

The inferior extensor retinaculum (IER) is an aponeurotic structure, which is in continuation with the anterior part of the sural fascia. The IER has often been used to augment the reconstruction of the lateral ankle ligaments, for instance in the Broström-Gould procedure, with good outcomes reported. However, its anatomy has not been described in detail and only a few studies are available on this structure. The presence of a non-constant oblique supero-lateral band appears to be important. This structure defines whether the augmentation of the lateral ankle ligaments reconstruction is performed using true IER or only the anterior part of the sural fascia. It is concluded that the use of this structure will have an impact on the resulting ankle stability. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to assess the feasibility of inferior extensor retinaculum (IER) reinforcement and analyze differences in clinical and radiographic outcomes based on whether or not IER reinforcement was performed in modified Broström procedures. Methods: Forty-one patients (41 ankles) who underwent ankle reconstruction with either a Broström procedure or modified Broström with IER reinforcement were included in this prospective study. During Broström procedures, feasibility of IER reinforcement was recorded. Clinical and radiographic outcomes were analyzed between modified Broström procedures (MBP group) in which IER reinforcement was feasible and Broström procedures (BP group) in which IER reinforcement was not feasible. Results: IER reinforcement was feasible in 31 cases (75.6%) and not feasible in 10 cases (24.4%) due to anatomic variations. The American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved in the MBP group from a preoperative mean of 66.3 to a postoperative mean of 89.4. In the BP group, the score increased from 71.3 to 89.8. The radiographic outcomes assessed by stress radiographs demonstrated that talar anterior translation and talar tilt improved from 6.3 mm to 4.6 mm and from 9.0 degrees to 5.0 degrees, respectively, in the MBP group. In the BP group, talar anterior translation improved from 6.9 mm to 4.9 mm and talar tilt, from 9.5 degrees to 4.9 degrees. No statistically significant difference was observed between the 2 groups. Conclusion: IER reinforcement was feasible in 75.6% of patients in whom modified Broström procedures had been planned. Postoperative clinical and radiographic outcomes were not significantly different based on whether or not IER reinforcement was performed. These findings suggest that isolated ligament reconstruction without IER may be sufficient to restore ankle stability. Level of Evidence: Level II, cohort study. [ABSTRACT FROM AUTHOR]

Background: No study in the paediatric literature-and only a single study in all of the literature-has evaluated the visualization frequency of the sinus tarsi ligaments on MRI. That 20-year-old study demonstrated only limited visualisation. Objective: The objective of this study is to re-evaluate the visualisation frequency of the sinus tarsi ligaments and to characterise their morphology on isotropic three-dimensional proton density imaging (3-D-PD). The authors hypothesise that by using 3-D-PD, these ligaments will be able to be demonstrated in nearly all paediatric patients. Materials and methods: Patients were scanned on either 1.5- or 3-Tesla scanners using 3-D-PD. Of 174 patients reviewed, 50 were identified who met inclusion and exclusion criteria. Results: The interosseous talocalcaneal ligament (ITC), the cervical ligament (CL) and the roots of the inferior extensor retinaculum (IER) were successfully visualised and characterised in three planes in 50 out of 50 children. The mean ligament thickness was 4.22 mm for the ITC, 2.74 mm for the CL and 1.04 mm for the IER roots. Conclusion: With modern parameters, the tarsal sinus ligaments can be visualised in 100% of patients, a percentage substantially higher than previously reported. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 23 year old male patient who presented to physicians with symptoms of painful snapping at the anterolateral aspect of his right ankle which had resulted from twisting his ankle while playing soccer. A discussion of diagnostic testing which was conducted on the patient and resulted in him receiving a diagnosis of an attenuated inferior extensor retinaculum, is presented.

Abstract: Anterior tarsal tunnel syndrome is a rare entrapment neuropathy of the deep peroneal nerve beneath the inferior extensor retinaculum of the ankle. We report a patient with anterior tarsal tunnel syndrome who was successfully treated with endoscopic anterior tarsal tunnel release. Our endoscopic technique, because it preserves the inferior extensor retinaculum, is potentially less traumatic than traditional surgical techniques for repairing this entrapment neuropathy. [Copyright &y& Elsevier]