This study aims to illustrate the assessment and treatment strategies of acute and chronic deltoid ligament injuries, providing a treatment algorithm for each scenario.

A retrospective review was conducted on 39 patients, who had either an acute deltoid ligament injury or suffered chronic deltoid ligament insufficiency. All patients were operated on between January 2016 and December 2022. The cases represent a range of different clinical scenarios, including acute trauma, chronic insufficiency or instability situations. Clinical and imaging evaluation, surgical techniques and clinical outcomes are presented.

The mean follow-up time was 21.3 months (±4.5). Acute trauma represented 18 (46%) of the ankles, while 21 (54%) had chronic instability. Treatment options were tailored according to the aetiology, patient characteristics, injury pattern and associated lesions. In 11 of the 18 acute deltoid ruptures (64%), repair was performed using suture anchors, while the remaining 7 cases were treated with direct suture. In chronic deltoid insufficiency, re-tensioning with suture anchor was performed in 14 (67%) ankles, suture imbrication in 5 (24%) and reconstruction in 6 (9%). The most common associated injuries were syndesmotic injuries (n = 12, 56%) and osteochondral lesions (n = 13, 36%). The complication rate was 18% (n = 7), the majority related to persistent stiffness (n = 4, 10%).

The decision on when and how to repair the deltoid ligament should be guided by the characteristics of the injury and the individual patient. The current treatment rationale may serve as a working basis for evaluating and treating these ankles.

Level IV.

Arthroscopic anterior talofibular ligament (ATFL) repair procedures generally involve either repair solely of the ATFL or repair of the ATFL with inferior extensor retinaculum (IER) reinforcement. Both techniques produce strong clinical outcomes; however, studies directly comparing ATFL repair techniques with and without IER reinforcement are limited. We hypothesize that patients receiving arthroscopic ATFL repair with IER reinforcement have superior clinical outcome scores.

A systematic review and meta-analysis per PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines was conducted. To assess the relationship of type of surgical procedure (repair of only the ATFL or repair of the ATFL plus IER reinforcement) to reported clinical outcomes based on the Karlsson and Peterson Scoring System for Ankle Function (KAFS), visual analog scale (VAS), and the American Orthopaedic Foot & Ankle Society (AOFAS) score, we used the standardized mean difference (SMD) with a 95% CI of preoperative to postoperative scores as an effect size. A meta-regression analysis was conducted to identify the source of differences in the observed effect size between studies.

A total of 638 studies met the initial search criteria. The meta-analysis included 34 studies to compare clinical outcomes of arthroscopic ATFL repair. Arthroscopic ATFL repair both with and without IER reinforcement resulted in significantly improved preoperative to postoperative clinical outcome scores. Arthroscopic ATFL repair with IER reinforcement resulted in a significantly higher preoperative to postoperative SMD for KAFS (P = .091) and VAS (P = .065) scores compared to arthroscopic ATFL repair without IER reinforcement. There was no significant difference in the preoperative to postoperative SMD of AOFAS (P = .453) scores when comparing surgical procedures. ATFL repair with IER reinforcement had a significantly greater rate of superficial peroneal nerve (SPN) injury (P = .004).

Arthroscopic ATFL repair with IER reinforcement leads to improved clinical outcome scores but carries a higher risk of SPN injury compared to arthroscopic ATFL repair without IER reinforcement. Patients receiving either arthroscopic procedure should achieve excellent functional outcomes.

This study explored whether adding transcranial direct current stimulation (tDCS) to balance exercises enhances preparatory brain activity and clinical outcomes in individuals with chronic ankle instability.

30 participants were randomised into two groups: balance exercises with real tDCS and balance exercises with sham tDCS. Neurophysiological measures, including late contingent negative variation (CNV) amplitude, peak amplitude and peak time, served as primary outcomes, while biomechanical (anticipatory postural adjustment duration) and clinical (dynamic balance and perceived ankle instability) outcomes were secondary. Both groups completed 12 sessions, each lasting 60 min.

The results revealed no significant group-by-time interaction for late CNV amplitude, CNV peak amplitude, perceived ankle instability scores or dynamic balance, indicating no added benefit of real tDCS over sham. However, both groups demonstrated significant post-treatment improvements in late CNV amplitude (C3, Cz, C4: p≤0.017, η2=0.177-0.276) and CNV peak amplitude at the C3 electrode (p=0.026, η2=0.158), reflecting enhanced preparatory brain activity. Similarly, dynamic balance improved significantly in the anterior, posterior-medial and posterior-lateral directions (p≤0.010, η2=0.204-0.350) and perceived ankle instability scores increased notably, indicating reduced instability (p<0.001, η2=0.391), regardless of the tDCS condition. Furthermore, significant correlations (r=0.381-0.553) were observed between treatment-induced changes in neurophysiological variables and biomechanical and clinical outcomes.

Although tDCS did not show a distinct advantage, the improvements in neurophysiological and clinical outcomes suggest that balance exercises effectively target central mechanisms. Additionally, relationships were found between enhancements in neurophysiological outcomes and other measures, emphasising the pivotal role of central mechanisms in driving these positive effects.

IRCT20210604051488N1.

To report results following deltoid ligament reconstruction in a large series of patients.

For consecutive patients who had a medial ankle ligament stabilization 2010-2018 information from their medical files was registered, and they were invited for follow-up in 2021-2022. They answered questions about satisfaction with the treatment and current symptoms, and they completed the Foot and Ankle Measurement (FAAM) questionnaire.

Of the 503 patients, 342 (68%) had a history of trauma to the ankle and 114 (23%) had previous ankle surgery. 67% had other procedures (besides synovectomy) simultaneous to medial ligament reconstruction. 269 patients (54%) responded to the invitation for follow-up. For 182 (71%) of the responders, the operation solved their ankle problems. 163 (63%) were satisfied with the surgery. 192 (71%) would repeat the operation. 173 (67%) had pain in the ankle during the past week, and 86 (50%) of these were not able to run. FAAM ADL-scores were significantly higher than in a mixed group of ankle/foot patients but not normal.

The relatively high degree of satisfaction despite suboptimal clinical results may reflect the complex nature of the deltoid ligament insufficient ankle. It is concluded that repair or reconstruction of the deltoid ligament is only performed in patients reporting ankle instability and with peroperatively demonstrated medial instability and pathology to the ligament.

Level III.

To develop a deep learning (DL) model that can simultaneously detect lateral and medial collateral ligament injuries of the ankle, aiding in the diagnosis of chronic ankle instability (CAI), and assess its impact on clinicians' diagnostic performance.

DL models were developed and externally validated on retrospectively collected ankle magnetic resonance imaging (MRI) between April 2016 and March 2022 respectively at 3 centers. Included patients had confirmed diagnoses of CAI through arthroscopy, as well as individuals who had undergone MRI and physical examinations that ruled out ligament injuries. DL models were constructed based on a multilabel paradigm. A transformer-based multilabel DL model (AnkleNet) was developed and compared with 4 convolution neural network (CNN) models. Subsequently, a reader study was conducted to evaluate the impact of model assistance on clinicians when diagnosing challenging cases: identifying rotational CAI (RCAI). Diagnostic performance was assessed using area under the receiver operating characteristic curve (AUC).

Our transformer-based model achieved AUCs of 0.910 and 0.892 for detecting lateral and medial collateral ligament injury, respectively, both of which were significantly higher than those of CNN-based models (all P < .001). In terms of further CAI diagnosis, there was a macro-average AUC of 0.870 and a balanced accuracy of 0.805. The reader study indicated that incorporation with our model significantly enhanced the diagnostic accuracy of clinicians (P = .042), particularly junior clinicians, and led to a reduction in diagnostic variability. The code of the model can be accessed at https://github.com/ChiariRay/AnkleNet.

Our transformer-based model was able to detect lateral and medial collateral ligament injuries based on MRI and outperformed CNN-based models, demonstrating a promising performance in diagnosing CAI, especially patients with RCAI.

Developing such an algorithm can improve the diagnostic performance of clinicians, aiding in identifying patients who would benefit from arthroscopy, such as patients with RCAI.

Background Chronic lateral ankle sprains are common injuries that are largely sequelae of inversion injuries of the ankle. These injuries are amenable to surgical intervention, namely, Broström-Gould reconstruction, which is commonly performed for the above injury. Many open and arthroscopic variations of the technique have been described. Arthroscopic Broström-Gould has been shown to have comparable outcomes to the open technique. Analysis of 39 patients who underwent arthroscopic Broström-Gould at a tertiary institution showed excellent outcomes from all three functional scores. Methods Thirty-nine patients underwent arthroscopic Broström-Gould in 2021 at a tertiary institution and were followed up for up to one year postoperatively. All patients had failed conservative treatment and reported pain and chronic instability prior to surgical intervention. Outcomes were measured with functional scores, namely, the visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS), and Karlsson and Peterson Scoring System (K-P). Other demographics such as age, gender, laterality, and body mass index were also recorded. Statistical analysis was performed with GraphPad Prism (GraphPad Software, San Diego, CA). Outcomes were analysed by paired t-test and statistical significance was set at p < 0.05. Results A total of 39 patients with chronic lateral ankle instability (CLAI) who underwent arthroscopic Broström-Gould were followed up for up to one year postoperatively. Demographics were as follows: 22 males and 17 females, 20 right ankles and 19 left ankles, average age of 36.2 years (19.6-64.8 years), and BMI of 27.4 (19.2-40). At follow-up, functional scores were measured as described in the methods section above. Preoperative VAS scores were 5.87 ± 1.92 (1-10) while postoperative VAS scores were 2.0 ± 2.16 (0-7). Preoperative K-P scores were 43.68 ± 13.2 (7-70) while postoperative K-P scores were 69.21 ± 17.86 (37-100). Preoperative AOFAS scores were 62.53 ± 16.05 (29-83) while postoperative AOFAS scores were 83.8 ± 11.49 (59-100). Conclusions Significant improvement of all three functional scores (VAS, K-P, and AOFAS scores) following arthroscopic Broström-Gould was noted. This shows that the arthroscopic Broström-Gould is an effective method to treat CLAI with good outcomes.

Medical research within areas of deep learning, particularly in computer vision for medical imaging, has shown promise over the past decade with an increasing volume of technical papers published in orthopaedics related to imaging artificial intelligence (AI). However, as more tools and models are developed and deployed, it is easy for clinicians to get overwhelmed with the different types of models, leaving "artificial intelligence" as an empty buzzword where true value can be unclear. As with surgery, the techniques of deep learning require thoughtful application and cannot follow a one-size-fits-all approach as different problems require differential levels of technical complexity with model application. Moreover, the application of AI-based clinical tools should be both adjunctive and transparent in their stepwise integration within clinical medicine to provide additive insight. As a medical profession, we must together decide how, when, and where we want AI-based applications to offer insight.

The combination of transcranial direct current stimulation (tDCS) with balance training could integrate central and peripheral neural mechanisms. This study aimed to investigate the effects of concurrent balance training and tDCS over the supplementary motor area (SMA) on anticipatory postural adjustments during gait initiation (GI) in persons with chronic ankle instability (CAI).

Balance training will increase the center of pressure (COP) velocity and displacement during GI phases in all participants, and those receiving real tDCS will show greater increases.

Randomized controlled trial.

Level 2.

A total of 32 subjects were allocated to 2 groups: (1) intervention (balance training plus real tDCS) and (2) control (balance training plus sham tDCS). Outcome measures were COP-related parameters (displacement and velocity) during phases of GI (anticipatory, weight transition, and locomotor).

The results showed that, in the anticipatory phase, the anteroposterior displacement of the COP was increased significantly at posttest relative to pretest across both groups, F(1,30) = 5.733, P = 0.02. In addition, both groups revealed an increase in the mediolateral COP velocity at posttest, F(1,30) = 10.523, P < 0.01. In the weight transition phase, both groups had higher mediolateral COP velocity at posttest, F(1,30) = 30.636, P < 0.01. In the locomotor phase, in both groups, the anteroposterior COP velocity was increased significantly at posttest compared with pretest, F(1,30) = 5.883, P = 0.02.

Both groups demonstrated improvements in the anticipatory and execution phases of GI. Since no between-group difference was found, it can be interpreted that the anodal tDCS applied over the SMA has no added value over sham stimulation.

Balance training is beneficial for persons with CAI and can improve the anticipation and execution phases of GI without the aid of brain stimulation.

Few studies reported the long-term clinical outcomes and joint degeneration of patients with chronic lateral ankle instability (CLAI) and small osteochondral lesions of the talus (OLTs) following simultaneous open modified Broström-Gould (MBG) surgery and arthroscopic bone marrow stimulation (BMS). The purpose of this study was to study the long-term results of patients after BMS and BMG surgery, and to further evaluate the potential effect of OLT size on postoperative results.

In this retrospective study, 110 CLAI patients were divided into 57 patients with OLTs (including 24 patients having combined small osteochondral lesions of the tibial plafond) receiving simultaneous BMS and MBG surgeries (BMS+MBG group), and 53 patients without OLTs receiving isolated open MBG surgery (MBG group). The OLT size and pre- and postoperative Kellgren-Lawrence grade were assessed. The subjective scores (visual analog scale pain score, Tegner activity, and Karlsson-Peterson scores), surgical complications, and return to sports were also compared pre- and postoperatively.

Patients were followed up at a mean of 144.2 ± 14.9 and 145.6 ± 11.4 months for the BMS+MBG and MBG groups, respectively. Subjective scores were significantly improved (P < .001), and no difference was found in subjective scores or surgical complications between the 2 groups (P > .05). Both groups showed progression of osteoarthritis grade (P < .001), but with no significant difference of changes from the preoperative to the final follow-up (BMS+MBG group: 0.84 ± 0.75 to 1.32 ± 0.80; MBG group: 0.32 ± 0.48 to 0.86 ± 0.56, changes: 0.48 ± 0.59 vs 0.55 ± 0.51, P = .575). For sports function, both groups had similar results in Tegner scores (5.8 ± 1.3 vs 6.2 ± 1.3, P = .081). However, in a subgroup analysis, we found that in the BMS+MBG group, patients exceeding the mean size of OLTs (50 mm2) were associated with an average lower postoperative Karlsson-Peterson score (P = .025) and higher postoperative osteoarthritis grade (P = .037), with more changes (P = .017) than those with OLTs <50 mm2.

Patients with CLAI and small OLTs following simultaneous open MBG surgery and arthroscopic BMS showed good long-term outcomes and only mild progression of joint degeneration-overall similar to patients treated for CLAI with MBG surgery. Moreover, as OLT size increased, good outcomes were less predictable.

Ankle sprains can lead to chronic lateral ankle instability (CLAI) in 10-50% of cases. While the anterior talofibular ligament (ATFL) is traditionally considered the primary structure affected, recent studies indicate a high incidence of combined injuries to the ATFL and the calcaneofibular ligament (CFL). Given the importance of the CFL, this study aims to evaluate the biomechanical efficacy of double tendon graft reconstruction of the ATFL and CFL in cases of CLAI.

This biomechanical study on cadaveric ankles compares two techniques: anatomical reconstruction using a double graft for both the ATFL and CFL versus isolated anatomical reconstruction of the ATFL with a single graft. Stability was assessed using specific examination maneuvers (anterior drawer, forced varus, and pivot shift) with an arthrometer measuring angular displacement across three spatial planes (horizontal, coronal, and sagittal). Four models were analyzed: intact ankle, sectioning of the ATFL and CFL, double graft reconstruction of the ATFL and CFL, and single graft reconstruction of the ATFL.

The results showed no significant differences between the double graft reconstruction and the intact ankle. Comparing the double graft with the single graft reconstruction revealed statistically significant differences, favoring the double graft for greater angular stability in the coronal plane during forced varus and external rotation maneuvers.

Double graft reconstruction of the ATFL and CFL provides greater angular stability compared to isolated ATFL reconstruction, demonstrating significant benefits in lateral and rotational stabilization of the ankle in CLAI cases.

To report and evaluate the time of return to work and sports of patients who underwent an anatomic arthroscopic reconstruction using allograft for chronic lateral ankle instability (CLAI) through 2 portals, and to analyze the functional results as well as the postoperative complications of the reconstruction surgery.

We retrospectively reviewed patients who underwent allograft arthroscopic reconstruction of anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) in the period from January 2018 to January 2022. The inclusion criteria encompassed patients with CLAI who (1) were older than 18 years old; (2) underwent arthroscopic ATFL and CFL reconstruction using allograft; and (3) had been followed up for at least 2 years. The operation was performed with 2 arthroscopic portals, a percutaneous incision for CFL reconstruction, and 2 knotless anchors. Time of return to work and sports was recorded. In addition, Karlsson Ankle Functional Score (KAFS), Tegner Activity Scale (TAS), visual analog pain scale (VAS), and visual analog scale for patient satisfaction (VASPS) were evaluated preoperatively and postoperatively, and all complications were documented at a minimum follow up of 2 years.

In total, 44 patients (mean age, 35.6 ± 9.7 years) were included, and the average follow-up duration was 29.6 ± 3.7 months (range, 24-42 months). The mean time of return to work was 3.29 ± 0.93 months, whereas the mean time of return to sports was 6.45 ± 1.55 months. KAFS increased from 53.91 ± 9.31 to 91.14 ± 6.03 (P < .001), mean TAS increased from 2.22 ± 1.05 to 7.34 ± 1.51 (P < .001), VAS decreased from 3.95 ± 1.71 to 0.43 ± 0.66 (P < .001), and VASPS increased from 1.11 ± 1.43 to 9.59 ± 0.76 (P < .001). All patients (100%) achieved the minimal clinically important difference in KAFS, VAS, TAS, and VASPS. Subgroup analysis indicated no statistically significant differences in functional outcomes regarding the presence/absence of associated intra-articular lesions and body mass index (greater or less than 25). Minor complications were observed in only 4 patients (9.1%).

Patients with CLAI who underwent arthroscopic allograft reconstruction of ATFL and CFL through 2 portals and an additional incision successfully returned to their preinjury occupations within 5 months. They also returned to their preinjury level of sports without restrictions, adaptations, or protective measures within 9 months. They demonstrated excellent clinical outcomes, as all patients (100%) achieved the minimal clinically important difference in KAFS, VAS, TAS, and VASPS at minimum of 24 months follow-up. However, 9.1% of patients had minor neurologic complications.

Level IV, retrospective therapeutic case series.

Chronic ankle instability (CAI) is a common and highly disabling condition. Although several studies have evaluated and analyzed prevention and treatment strategies for CAI, an unbiased and systematic synthesis of evidence is required to provide the most powerful and comprehensive evidence-based measures for the its prevention and treatment of CAI. This study aimed to synthesize evidence from the existing literature addressing the treatment and prevention of CAI.

The PubMed, Embase, Cochrane, and Web of Science databases were systematically searched for relevant studies from inception to December 12, 2023. Data on effect sizes and corresponding 95 % confidence intervals for selected intervention measures were extracted. Systematic reviews were assessed for quality of included studies using a measurement tool (i.e., "AMSTAR 2").

In total, 37 studies were included, among which 21 (57 %) were of high or moderate quality. Strong evidence suggested that lower weight (P < 0.001), lower body mass index (P = 0.002), and non-stability defects (P = 0.04) significantly reduced the risk of developing CAI. Strong evidence supported exercise and moderate evidence supported manual therapy, acupuncture, and surgery for improving CAI. Additionally, external support plays an active role in the treatment process of CAI.

This is the first study synthesizing evidence supporting interventions for the treatment and prevention of CAI. Low body weight and body mass index were effective preventive measures against CAI. Exercise, manual therapy, acupuncture, and surgery can improve ankle function in patients with CAI. Plantar sensory treatment and neuromuscular training may be good therapeutic options for patients with CAI.

Level I.

Tendon and ligament disorders are common indications for ankle surgery. Numerous surgeries and related modifications, ranging from simple repairs and debridement to complex reconstructions with tendon transfers or graft, are available. Knowledge of postoperative imaging appearances of common ankle surgeries is critical to identify complications and aid assessment of clinical treatment failure. This comprehensive review article discusses the surgical indications, techniques, imaging appearances, and complications-specifically those related to minimally invasive or arthroscopic surgery-for various ankle and foot conditions. It includes anatomical (Brostrom type) and nonanatomical lateral ligament repairs for ankle instability. Medial compartment procedures are described, such as peroneal tendon and retinacular repairs, as well as treatments for progressive collapsing flatfoot deformity, formerly known as posterior tibial tendon dysfunction or acquired flatfoot deformity. We also examine posterior compartment procedures, focusing on Achilles tendon repairs. Primary imaging modalities covered are magnetic resonance imaging, ultrasound, computed tomography, and radiographs, including expected postoperative appearances and the usefulness of each modality.

At present, the modified suture augmentation (MSA) repair and the InternalBrace™ (IB) reconstruction techniques are commonly used for the treatment of chronic ankle instability (CAI). This study aimed to evaluate and compare the clinical efficacy of the MSA repair and IB reconstruction techniques, providing a reference for clinical practice.

After propensity score matching, 50 patients with CAI between May 2021 and May 2022 were included in this retrospective study. Of these, 26 underwent IB reconstruction surgery and 24 underwent MSA repair surgery. The American Orthopedic Foot and Ankle Society (AOFAS) scores, visual analog scale (VAS) scores, anterior drawer tests, and patient satisfaction were used for clinical efficacy evaluation.

The postoperative AOFAS scores in the MSA group (88.8 ± 3.0) were significantly higher than those in the IB group (84.3 ± 5.4, P = 0.001). However, the patient satisfaction scores in the IB group (7.3 ± 0.8) were higher than those in the MSA group (6.7 ± 0.8, P = 0.02). There were no significant differences between the two groups in the anterior drawer test results and VAS scores (P < 0.05). In addition, regarding postoperative complications, only one patient (4.2%) in the MSA group had joint laxity.

MSA repair was superior to IB reconstruction in terms of AOFAS scores. However, IB reconstruction was superior in terms of patient satisfaction. These findings highlight the potential of MSA repair and IB reconstruction techniques for the treatment of CAI.

The treatment of chronic ankle sprains has largely focused on lateral ankle instability in the literature. There is a scarcity of data regarding the diagnosis and management of chronic medial ankle instability secondary to deltoid ligament injury.

A literature search was performed using the National Center for Biotechnology Information (NCBI) database for studies evaluating chronic ankle instability (CAI) involving deltoid ligament pathology. Studies were evaluated for workup including clinical presentation, imaging, treatment algorithm and operative techniques. Descriptive statistical analysis was conducted across the pooled data set.

Nine studies representing 516 patients with CAI were included in our analysis. Plain radiographs assessed talar-tilt angle in 440 patients (85%) and anterior displacement in 296 patients (57%). A total of 465 patients underwent magnetic resonance imaging, with deltoid injuries identified in 289 (62%) of patients. Of these 289 patients, superficial deltoid involvement was specified in 61 patients and deep deltoid in 146 patients. Surgical treatment most commonly included arthroscopy in 255 patients with open deltoid ligament repair in 199 patients. Repair method included suture anchors in 173 patients (87%), bone tunnels in 23 patients (12%), and unspecified technique in 3 patients (1.5%). Thirteen patients (6.5%) had suture anchor repairs augmented with an internal brace. Three patients underwent deltoid reconstruction with plantaris tendon autograft.

Deltoid ligament injuries are common in patients with CAI. These data improve our understanding of chronic deltoid injuries and can help patients and surgeons better comprehend the pathoanatomy of chronic ankle instability.

Level III, retrospective cohort study.

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.

A gold standard surgical treatment for osteochondral lesions (OCLs) of the talus still needs to be established. Still, autologous matrix-induced chondrogenesis (AMIC) is a commonly applied 1-stage procedure that has achieved good short- and mid-term results. The present cohort study aimed to assess whether the long-term, 10-year results can confirm the previous findings.

All patients underwent an open AMIC procedure using a collagen type I/III bilayer matrix for a talar OCL. General demographic data, preoperative magnetic resonance imaging findings, intraoperative details, and German version of the Foot Function Index (FFI-D) scores preoperatively and at 1, 5, and 10 years as well as European Foot and Ankle Society (EFAS) and American Orthopedic Foot & Ankle Society (AOFAS) scores at 10 years after surgery were analyzed. The primary outcome variable was the procedure's longitudinal effect, and several variables' influence on the outcome was tested.

Of 47 consecutive patients, 18 (38%) were included. Of the 18 patients, 6 (33%) were female, and 12 (67%) were male, with a mean age of 39 ± 15 (range = 15-62) and an average body mass index (BMI) of 26 ± 5 (range = 20-38) kg/m². The mean defect size was 1.4 ± 0.9 (range = 0.2-4) cm². The FFI-D total score showed a significant decrease from preoperatively to 1 year postoperatively (56 ± 19 to 34 ± 27; P = 0.001) with a further nonsignificant decrease to the 5-year (34 ± 27 to 21 ± 20; P = 0.16) and 10-year follow-up (21 ± 20 to 15 ± 13; P = 1.00). All the single items decreased significantly from preoperatively to the 5- and 10-year mark. Although not significant, most items improved from 5 to 10 years postoperatively. Age positively correlated with the preoperative, 5-year, and 10-year follow-up FFI-D total score.

AMIC, as a single-step surgical intervention, is a viable long-term treatment option. Patient selection regarding symptoms and findings is vital to achieve satisfying results.

The medial collateral ligament of the ankle, or deltoid ligament, can be injured in up to 40% of patients who sustain an ankle inversion sprain. Reporting injuries of the deltoid ligament is not easy due to confusion in the current anatomical descriptions, with up to 16 fascicles described, with variable frequencies. The purpose of this study was to clarify the anatomy of the deltoid ligament.

Thirty-two fresh-frozen ankle specimens were used for this study. Careful dissection was undergone until full visualization of the deltoid ligament was achieved and measurements taken.

The deltoid ligament was found to have four constant fascicles in two layers. The superficial layer consists of the tibionavicular, tibiospring and tibiocalcaneal fascicles, while the deep layer consists of the tibiotalar fascicle. Measurements of these fascicles are given in detail. The tibiotalar fascicle and the anterior part of the tibionavicular fascicle were found to be intra-articular structures.

The deltoid ligament has a constant number of fascicles divided into a superficial and a deep layer. This clarification of the anatomy and terminology of the deltoid ligament and its fascicles will help clinical view, diagnosis and (interdoctor)communication and treatment. The ligamentous fibres of the deep layer, as well as the anterior fibres of the superficial layer (tibionavicular fascicle) are intra-articular, which could negatively impact its healing capacity, explaining chronicity of these types of injuries.

Not applicable (cadaveric study).

Ankle sprains remain the most common soft tissue injury presenting to Emergency Departments. Recently, there has been increased awareness and reporting of deltoid ligament injuries in association with injuries to the lateral ligament complex as well as with fibula fractures. This article reviews the currently available literature on the anatomy of the deltoid ligament, clinical and radiological diagnosis of injuries to the deltoid ligament and treatment recommendations.

A literature review was conducted for keywords associated with deltoid ligament injuries. MEDLINE, PubMed and Embase databases were utilised for this search. Articles were included if involving an adult population, were English-language, were related to deltoid ligament injuries (with or without associated injuries) and reported on patho-anatomy, clinical or radiological diagnosis or treatment methods.

A total of 93 articles were assessed for relevance from the database search, and 47 were included after the removal of irrelevant articles and duplicates. Several studies reported on the clinical findings of deltoid ligament injury, as well as the radiographic analysis. Arthroscopy was considered the gold standard of diagnosis, with authors reporting on the potential benefit of performing arthroscopic repair or reconstruction at the same time. There were no studies that provided a system for the classification of deltoid ligament injury or larger studies of treatment pathways. Long-term studies of the incidence of instability in deltoid ligament injuries were not available.

There is limited evidence available regarding deltoid ligament injuries, particularly in terms of treatment options, either in isolation or with concomitant injuries. Long-term follow-up studies are needed to obtain more accurate data on the number of complications.

Level IV.

Although arthroscopic repair of the deltoid ligament is becoming a popular procedure, no studies have assessed which bundles of the deltoid ligament can be reached by anterior ankle arthroscopy. This study aimed to assess the feasibility of the arthroscopic repair of the deep layer of the deltoid ligament. In addition, it aimed to correlate which fascicle of the superficial layer of the deltoid ligament corresponds to the deep fascicle visualised by arthroscopy.

Arthroscopy was performed in 12 fresh frozen ankles by two foot and ankle surgeons. With the arthroscope introduced through the anterolateral portal, the medial compartment and the deltoid ligament were explored in ankle dorsiflexion without distraction. Using a suture passer introduced percutaneously, the most posterior fibres of the deep deltoid ligament visualised by anterior arthroscopy were tagged. Then, the ankles were dissected to identify the deep and superficial bundles of the deltoid ligament tagged with a suture.

In all specimens (100%), the intermediate part of the tibiotalar fascicle, corresponding to the fibres originating from the anterior colliculus, was tagged with a suture. The posterior part of the tibiotalar fascicle was never tagged with a suture. In all specimens, the intermediate part of the tibiotalar fascicle grasped by the suture correlated with the tibiospring fascicle of the superficial layer.

The current study demonstrates the feasibility of the arthroscopic repair of the deep fascicle of the deltoid ligament. By performing anterior arthroscopy, it is possible to visualise and repair the intermediate part of the tibiotalar fascicle (deep layer of the deltoid ligament). These fibres correspond to the tibiospring fascicle of the superficial layer. The clinical relevance of the current study is that the arthroscopic repair of the deep layer of the deltoid ligament is feasible through anterior ankle arthroscopy.

Not applicable.

Rotational ankle instability is a multiligamentous injury defined as an overload injury of the deltoid ligament caused by a long-standing injury of the lateral collateral ligament in patients affected by chronic ankle instability. The purpose of the study was to compare the clinical outcomes of combined arthroscopic repair of lateral and medial ankle ligaments for rotational ankle instability versus isolated arthroscopic lateral ligament repair for lateral ankle instability at 2 years' follow-up.

Between 2019 and 2021, 108 patients with chronic ankle instability were consecutively treated by arthroscopy. Of this group, 83 patients (77%) [median age: 26 (range, 14-77) years] underwent an isolated all-inside lateral ligament repair for lateral ankle instability (group A). In the remaining 25 patients (23%) [median age: 27 (range, 17-58) years], rotational ankle instability was clinically suspected and confirmed during arthroscopy; thus, a combined all-inside repair of lateral and medial ligaments was performed (group B). The same postoperative protocol was utilised for both groups. Patients were prospectively evaluated before surgery, at 3, 6, 12 and 24 months with Foot Functional Index (FFI) score, visual analogue scale (VAS) and Foot and Ankle Ability Measure-Sports subscale (FAAM-SS). At the latest follow-up, the satisfaction rate and complications were also recorded.

In both groups, FFI, VAS and FAAM-SS scores significantly improved compared to preoperative values (p < 0.001). In addition, according to all the scores evaluated, there was no significative difference (n.s) between groups at the final follow-up or at any of the intermediate follow-up. No major complications were observed in both groups.

Arthroscopic ligament repair in case of ankle multiligamentous injuries, such as in rotational ankle instability, provides excellent clinical outcomes and is comparable to isolated lateral ligament repair at 2 years' follow-up. Therefore, when treating ankle instability, arthroscopic repair of each and every ligament that appears injured provides the best potential outcomes and is the recommended treatment.

Level II, prospective comparative.

The ankle infrequently develops primary osteoarthritis (OA), especially when compared to the hip and the knee. Ankle OA instead generally develops only after trauma. The consequences of end-stage ankle OA can nonetheless be extremely debilitating, with impairment comparable to that of end-stage kidney disease or congestive heart failure. Disconcertingly, evidence suggests that ankle OA can develop more often than is generally appreciated after even low-energy rotational ankle fractures and chronic instability associated with recurrent ankle sprains, albeit at a slower rate than after more severe trauma. The mechanisms whereby ankle OA develops after trauma are poorly understood, but mechanical factors are implicated. A better understanding of the prevalence and mechanical etiology of post-traumatic ankle OA can lead to better prevention and mitigation. New surgical and conservative interventions, including improved ligamentous repair strategies and custom carbon fiber bracing, hold promise for advancing treatment that may prevent residual ankle instability and the development of ankle OA. Studies are needed to fill in key knowledge gaps here related to etiology so that the interventions can target key factors. New technologies, including weight bearing CT and biplane fluoroscopy, offer fresh opportunities to better understand the relationships between trauma, ankle alignment, residual ankle instability, OA development, and foot/ankle function. This paper begins by reviewing the epidemiology of post-traumatic ankle OA, presents evidence suggesting that new treatment options might be successful at preventing ankle OA, and then highlights recent technical advances in understanding of the origins of ankle OA to identify directions for future research.

The purpose of this study is to provide a detailed description of the anatomy and radiology of the medial sleeve and present an approach in its management among elite athletes.

Five cases of elite athletes who underwent treatment for a medial sleeve injury of which the diagnosis was confirmed through physical examination and additional magnetic resonance imaging scan are described in this study.

Two patients presented with isolated medial sleeve injuries, while the other three patients suffered from concomitant ankle injuries. Non-operative treatment consisted of relative rest, soft cast immobilization and mobilization in a walking boot or kinesiotape which was successful in four of the cases with regard to the medial sleeve. One patient underwent surgery due to syndesmotic instability. Another patient presented with combined medial and lateral ankle instability which was treated surgically with an open medial and lateral ligament repair. All patients were able to return to their pre-injury sports and at the time of the last follow-up were still playing in their pre-injury level of competition.

Medial sleeve injuries of the ankle in elite athletes should be considered in the differential diagnosis for athletes presenting with medial ankle pain. Inherent knowledge regarding anatomy is essential when guiding the management of these injuries which can be treated successfully with a non-operative approach consisting of relative rest, immobilization, kinesiotape and physical therapy. In case of persistent medial instability or rotational instability, surgical repair is a viable treatment option. Both modalities allow athletes to return to the pre-injury level of competition. However, early diagnosis is crucial to minimize the delay of appropriate treatment and avoid potential residual symptoms.

Level IV.

Although neuromuscular training (NMT) programmes positively enhance clinical deficits in chronic ankle instability (CAI) patients, the effectiveness of NMTs in restoring movement patterns during jump landing is still questionable. Before developing new prolonged motor-learning interventions, it is important to determine the immediate effects of intervention on movement patterns during jump-landing in patients with CAI. Therefore, the purpose of this study was to determine whether real-time external feedback using a crossline laser device changes the movement patterns during jump-landing and balance tasks in patients with CAI. Eighteen patients with CAI completed three successful single-leg jump-landing tasks and single-leg balance tasks under the conditions of with and without external feedback. Lower-extremity joint angles, moments, and EMG activation of six muscles were collected during the single leg jump-landing task and centre of pressure data were collected during the single-leg balance test. Real-time external feedback allowed to change neuromechanical characteristics in the entire lower-extremity (i.e., ankle, knee, and hip joints) during jump-landing. However, there were no differences in static postural control between the two conditions. Clinicians should carefully consider incorporating a cost-effective laser device into an augmented NMT programme of longer duration to improve movement patterns during functional tasks in patients with CAI.

Autologous osteoperiosteal transplantation (AOPT) is one of the most feasible and effective techniques for cystic osteochondral lesions of the talus (OLT). However, few reports have been reported about the process of graft-host bone healing and bone articular surface reconstruction, which help us to further understand the actual situation of bone healing and modify surgical methods.

The case series study retrospectively evaluated 33 osteochondral lesions in 30 patients undertaking AOPT for OLT with subchondral cysts from December 2016 to October 2021. According to CT observation, we used 4 variables to describe the bony articular repair, including the integration of the articular surface, the height of the bone filling, the status of bone union, and the appearance of bone resorption or cystic change. We also analyzed the demographic data and clinical function. Descriptive statistics were used for demographic and clinical variables. Normally distributed data were presented as mean ± SD, and non-normally distributed data were presented as median (Q1, Q3). Associations between these variables and the primary clinical outcomes were examined using t-test or one-way ANOVA test for continuous variables.

The patients' mean age was (41.7 ± 14.0) years old and the mean follow-up time was (29.6 ± 17.8) months. The chondral lesion size was (14.3 ± 4.1) mm. The cyst depth was (10.9 ± 3.7) mm. Significant improvements were observed in functional outcomes (according to the numeric rating scale for pain when walking and the American orthopedic foot and ankle society score) between the preoperative and latest follow-up evaluations, from 4.2 ± 2.1 to 2.2 ± 2.0 (p < 0.001), and from 66.8 ± 12.9 to 83.2 ± 10.4, respectively (p < 0.001). The overall satisfaction reached 8.3 of 10 points. All patients returned to sports and their median daily steps reached 8000 steps with 27 (81.8%) patients walking over 6000 steps daily. According to CT observation, "discontinuous bony articular surface and gap > 1 mm" was found in 27 grafts (81.8%), and "below the level of the adjacent articular surface, ≤ 1 mm" in a third of the grafts. Abnormal height of bone filling affected numeric rating scale score (p = 0.049) and American Orthopedic Foot and Ankle Society score (p = 0.027). Of note, bone resorption or cystic changes appeared in up to 13 autografts (39.4%).

AOPT is an effective and acceptable technique for cystic OLT. Bone reconstruction is essential for large cystic OLT. How to get better bony articular reconstruction and avoid cyst recurrence should still be paid more attention.

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.

Surgical repair or reconstruction of lateral ankle ligaments is indicated in patients with persistent ankle instability, with arthroscopic/endoscopic treatment becoming more frequent. Although presurgical imaging of the ankle is always standard procedure, more is needed to understand the evolution of the repaired ligament or the tendinous graft to help improve length of postoperative time and functional results. This review describes the normal ultrasound aspects and possible complications of repaired/reconstructed ankle ligaments after an all-inside endoscopic repair/reconstruction of the anterior talofibular ligament and the calcaneofibular ligament.

The anatomical location for lateral ligament reconstruction remains a significant challenge. With the development of arthroscopic technology, arthroscopic-assisted lateral ligament reconstruction can significantly facilitate the correct localization of anatomical points. However, there is limited evidence on the clinical efficacy of arthroscopic ligament reconstruction compared with percutaneous ligament reconstruction.

This study included 72 patients who underwent lateral ligament reconstruction for chronic lateral ankle instability from 2018 to 2022. The follow-up duration in the percutaneous(n = 35) and the arthroscopic(n = 37) groups was 6-30 months. The patients were evaluated before the operation, at 6 months after surgery, and at the final follow-up. The American Orthopaedic Foot and Ankle Society score (AOFAS), Karlsson-Peterson score, and Visual Analog Scale (VAS) were evaluated at each time point. The complications and the time required to return to sports were documented during the follow-up.

All clinical evaluations significantly improved after surgery in both groups. There was no significant difference between the two groups in the AOFAS score, VAS score, and complications. The Karlsson-Peterson score (85.4 vs 83.6, p = 0.044), surgical duration (50.4 min vs 60.2 min, p < 0.001), and time to return to sports (17.8 weeks vs 20.5 weeks, p = 0.033) were all improved in the arthroscopic group.

Satisfactory clinical outcomes can be achieved through both arthroscopic and percutaneous anatomic ligament reconstruction. The ligament remnant and anatomical localization point can be observed directly by using an arthroscope. Arthroscopic ligament reconstruction can be a more viable alternative for patients with chronic ankle instability due to its minimal disturbance to the stump of the ligament and reduced operative aggression.

Syndesmotic complex injuries are supposedly associated with injuries to the deltoid ligament (DL) complex. Several syndesmosis classifications take DL injuries into account when rating the stability of the syndesmotic injury. Still, no study has yet assessed the frequency and severity of DL injuries in unstable syndesmotic injuries. The aim of this retrospective cohort study was to assess both the severity of the syndesmotic and DL injury in patients undergoing surgery for an unstable syndesmotic injury.

The integrity of the syndesmotic and DL complex of 37 patients were assessed on MRI by 2 musculoskeletal radiologists. Eligible were adult patients with an acute, isolated, unstable syndesmotic injury (ligamentous or bony avulsions) who underwent surgery. The DL complex was classified as having 3 superficial (TNL/TSL/TCL) and 2 deep (aTTL/pTTL) components. Grade 0 indicated an intact ligament; grade I showed a periligamentous edema; grade II a partial tear presenting as laxity, irregular contour, or partial discontinuity with concomitant hyperintense signaling; grade III a complete tear; or grade IV in case of an avulsion fracture. Frequency and severity of DL injuries were assessed, and possible injury combinations analyzed using an h-cluster analysis and Mann-Whitney U test.

Mean severity (grade 0-3) was 2.6 ± 0.8 for the syndesmotic complex and 1.6 ± 1.1 for the DL (superficial 1.5 ± 1.1, deep 1.6 ± 1.1). Seven patients (19%) had no (n = 3; 8%) or minor (grade 1: n = 4; 11%) DL injuries. Overall, 2 different patient clusters and 4 separate ligament clusters were identified.

Unstable syndesmotic injuries can occur isolated or with an accompanying DL injury. There appears to be a great heterogeneity between the severity of syndesmotic and deltoid ligament injuries.

Surgical management of chronic lateral ankle instability has traditionally been performed using an open technique. Arthroscopic-assisted and all-arthroscopic techniques have gained popularity as they have achieved strong clinical outcomes. However, they rely on the surgeon's arthroscopic skills and familiarity with arthroscopic anatomy. Recently, a minimally invasive percutaneous technique without arthroscopic assistance has been developed that incorporates the benefits of arthroscopy, such as minimal soft tissue disruption, without the additional requirements of performing an arthroscopic technique. The aim of the current study is to describe the minimally invasive percutaneous technique for chronic lateral ankle instability and report on its clinical outcomes.

Fifty-four consecutive patients without intra-articular ankle pathology underwent lateral ligament repair for chronic ankle instability with a percutaneous technique at a single institution by a fellowship-trained foot and ankle surgeon. Foot Function Index (FFI) score was recorded pre-operatively and post-operatively at final follow-up. All patients had a minimum follow-up of 12 months. Post-operative complications and patient satisfaction were also recorded.

A significant improvement (p < 0.001) in FFI compared to pre-operative values (from 55, SD 4.1, to 10, SD 1.9) was observed. A single patient required a return to the operating room for open revision with allograft reconstruction following a fall 2.5 months post-operatively. There were no other complications including infection or nerve injury. The overall rate of satisfaction after surgery was 98.1%, with one patient dissatisfied due to excessive ankle stiffness.

The described minimally invasive percutaneous Brostrom procedure is safe and effective for the treatment of chronic lateral ankle instability without intra-articular ankle pathology.

Ligamentous lesions of the ankle joint are common. Isolated medial ligament injuries are rare but are often associated with lateral ligament injuries, isolated medial ligament lesions are often overlooked. The present study aimed to evaluate the clinical and functional differences in the outcomes of isolated lateral and combined medial and lateral ligament reconstruction. The study is based on patient-reported outcome measurements and motion sensor technology to assess these outcomes.

The purpose of this study was to compare the clinical and functional outcomes of isolated lateral and combined lateral and medial ankle ligament reconstruction.

From December 2014 to August 2018, 111 patients underwent either isolated lateral ligament (LG) or medial and lateral ligament (MLG) reconstruction. Of the 104 patients meeting the inclusion criteria, 49 had LG and 55 had MLG reconstruction. Outcome measures included the Short Form-36 Health Survey SF-36, Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAMG), Tegner Activity Scale, the European Foot and Ankle Society (EFAS), American Orthopaedic Foot and Ancle Society (AOFAS) hindfoot score, and the Karlsson Peterson Score. Mobility and stability were assessed using the Ortheligent™ motion sensor for both healthy and treated ankles.

While there were no significant differences in outcome scores between the groups, overall scores improved after treatment (p >0.00). Notably LG showed improved movement, with better dorsal extension measured by the Sensor (p ÷ 0.02). The sensor's results correlated significantly with FAOS subscales for pain (p ÷0.05), stiffness (p ÷ 0.01), ADL (p ÷0.02), and sports (p >0.00).

Postoperative results, regardless of LG or MLG, showed significant subjective well-being improvement. LG's advantages were highlighted by a significant improvement in dorsal extension, supported by correlated results from a portable motion sensor assessing ankle stability.

Objectives This study aimed to investigate the relationship between ankle ligamentous injuries and osteochondral defects (OCDs) and to determine the incidence of these conditions within the Saudi Arabian population. Methods This retrospective cohort study included 215 patients (110 males and 105 females) who sought medical advice for an ankle injury at our institute from January 2017 to August 2022. The patients were divided according to age, sex, presence and type of ligamentous injury, and status of OCDs. Patients' ages were categorized into three groups: younger than 30 years (48 patients), 30-60 years (145 patients), and older than 60 years (22 patients). The patients were assessed for ligamentous ankle sprains, tears, and OCDs by reviewing their magnetic resonance imaging reports from radiology records. The exclusion criteria included ankle fracture, ankle surgery, osteoarthritis of the ankle joint, inflammatory arthritis, and congenital deformity of the ankle. The data were collected using a simple questionnaire created via Google Forms. Results Of the 24 patients with OCD, 23 had OCD of the talus. Anterior talofibular ligament (ATFL) injury was the most common injury (75 patients), whereas posterior talofibular ligament (PTFL) injury was the least common. The only significant relationship between ligamentous injury and OCD was observed between PTFL injury and OCD of the talus (P = 0.041). Conclusions In patients with an ankle injury, the most common OCDs occur at the talus, whereas the most injured ligament is the ATFL. Nevertheless, a significant relationship was observed between PTFL injury and OCD of the talus. The findings underscore the importance of considering specific ligament injuries when diagnosing and managing OCDs, especially in patients with chronic ankle pain.

To investigate the effects of transcranial direct current stimulation (tDCS) combined with Bosu ball training on the injury potential during drop landing in people with chronic ankle instability (CAI).

A total of 40 participants with CAI were recruited and randomly divided into the tDCS + Bosu and Bosu groups. The people in the tDCS + Bosu group received intervention of tDCS combined with Bosu ball training, and those in the Bosu group received intervention of sham tDCS and Bosu ball training, for 6 weeks with three 20-min sessions per week. Before (week0) and after (week7) the intervention, all participants drop-landed on a trap-door device, with their affected limbs on a moveable platform, which could be flipped 24° inward and 15° forward to mimic an ankle inversion condition. The kinematic data were captured using a twelve-camera motion capture system. Two-way ANOVA with repeated measures was used to analyze data.

Significant group-by-intervention interactions were detected in the peak ankle inversion angular velocity (p = 0.047, η2 p = 0.118), the time to peak ankle inversion (p = 0.030, η2 p = 0.139), and the plantarflexion angle at the moment of peak ankle inversion (p = 0.014, η2 p = 0.173). Post hoc comparisons showed that compared with week0, the peak ankle inversion angular velocity and the plantarflexion angle at the moment of peak ankle inversion were reduced, the time to peak ankle inversion was advanced in both groups at week7, and the changes were greater in the tDCS + Bosu group compared to the Bosu group. And, a significant intervention main effect was detected in the peak ankle inversion angle in the two groups (p < 0.001, η2 p = 0.337).

Compared with the Bosu ball training, the tDCS combined with Bosu ball training was more effective in reducing the injury potential during drop landing in people with CAI.

The purpose of this study was to examine the changes in annual incidence and patient population undergoing lateral ankle ligament repair (LALR) for the surgical treatment of chronic ankle instability. The IBM Watson Health MarketScan Database was queried for patients who underwent LALR from January 2009 to December 2019 based on CPT code 27698. Volume and incidence per 100 000 population were determined for annual sums, gender, age, and geographical regions based on population estimates from the United States Census Bureau. Future annual volumes were statistically projected with linear regression modeling to the year 2032. Overall, 160 457 LALR procedures were identified in the database from 2009 to 2019. Annual incidence increased 76.6% from 3.46 to 6.11 cases per 100 000 population, while estimates of annual volumes are projected to increase 61.5% from 19 829 to 32 033 procedures to the year 2032. Interestingly, the greatest increase in incidence was observed among patients above 70 years old, which might suggest older patients are staying active longer and desiring elective procedures to maintain their activity levels. As the incidence of LALR increases in older patients, more research will be needed to understand the unique surgical considerations and risk factors impacting patient-reported outcomes.Level of Evidence: Level IV.

Although the all-inside arthroscopic modified Broström operation (AMBO) and open modified Broström operation (OMBO) for chronic lateral ankle instability (CLAI) showed favorable outcomes up to 1-year short-term follow-up, concerns about the long-term stability of AMBO are still present. Therefore, we aimed to compare midterm outcomes between the 2 methods by extending the observation period.

Fifty-four patients undergoing ankle surgery between August 2013 and July 2017 were included in the AMBO (n = 37) and OMBO (n = 17) groups. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and a visual analog scale (VAS) were used to evaluate the clinical outcomes. Anterior drawer test and talar tilt angle were used to evaluate the radiological outcomes. The mean follow-up duration was 59.69 months.

The 2 groups both showed improved clinical and radiological results statistically. In addition, they did not differ in age, sex, or preoperative AOFAS ankle-hindfoot scale score, VAS score, anterior drawer test, or talar tilt angle. No significant difference in the final follow-up postoperative clinical scores or radiological outcomes was observed.

AMBO and OMBO as treatments for CLAI did not yield differing clinical or radiological outcomes at a mean follow-up time point of 59.69 months.

A comprehensive understanding of the anatomy of the anterolateral ankle joint and its interrelationships is essential for advancing the development of minimally invasive Broström-Gould procedure, thereby enhancing surgical efficacy and minimizing postoperative complications.

Ten fresh human ankle specimens were dissected to observe the shape and trajectory of the lateral bundle of the inferior extensor retinaculum (IER) and its relationship with the deep fascia. To observe the relationship between the ankle capsule and the anterior talofibular ligament (ATFL). The center of the insertion point of ATFL at the lateral malleolus was used as the reference point. The vertical distance from the reference point to the fibula tip, the horizontal distance from the reference point to the lateral branch of the superficial peroneal nerve, the shortest distance from the reference point to IER, the narrowest width of the IER, the angle between the line connecting the shortest distance from the reference point to the IER and the longitudinal axis of the fibula were measured. The tension and elasticity of ATFL was understood. To describe the minimally invasive Broström-Gould procedure according to the anatomical characteristics of the anterolateral ankle joint.

Among the 10 cases, 8 cases (80%) had double bundles of ATFL, 2 cases (20%) had single bundle of ATFL, and no outer superior oblique bundle was observed in IER. The vertical distance from the reference point to the fibula tip was 1.2 ± 0.3 (range 1.1-1.3) mm. The shortest distance from the reference point to the level of the superficial peroneal branch was 28.2 ± 4.3 (range 24.5-32.4) mm. The shortest distance from the reference point to IER was 12.5 ± 0.6 (range 12.1-12.9) mm, and the width of IER at this point was 7.2 ± 0.3 (range 7.0-7.6) mm. The angle between the line connecting the shortest distance from the reference point to the IER and the longitudinal axis of the fibula was about 60° ± 2.8° (range 58.1°-62.1°) mm. The space between the anterolateral deep fascia of the ankle joint and the ankle capsule is very small, and only a few fat granules are separated between them. The ATFL is largely fused to the ankle capsule. The ATFL exhibited high tension and poor elasticity after traction with the probe hook.

The results showed that in the minimally invasive Broström-Gould technique for lateral ankle stabilization, the Broström procedure actually sutured the insertion of the ATFL together with the ankle capsule to the anterior edge of the lateral malleolus. In the Gould procedure, the deep fascia was mostly reinforced with the ankle capsule. The minimum suture span was obtained when the Gould suture needle direction was at an Angle of 60° to the longitudinal axis of the fibula.

Ankle sprains are prevalent in sports, often causing complex injuries to the lateral ligaments. Among these, anterior talofibular ligament (ATFL) injuries constitute 85%, and calcaneofibular ligament (CFL) injuries comprise 35%. Despite conservative treatment, some ankle sprain patients develop chronic lateral ankle instability (CLAI). Thus, this study aimed to investigate stress response and neural control alterations during landing in lateral ankle ligament injury patients.

This study recruited twenty individuals from a Healthy group and twenty CLAI patients performed a landing task using relevant instruments to collect biomechanical data. The study constructed a finite element (FE) foot model to examine stress responses in the presence of laxity of the lateral ankle ligaments. The lateral ankle ligament was modeled as a hyperelastic composite structure with a refined representation of collagen bundles and ligament laxity was simulated by adjusting material parameters. Finally, the validity of the finite element model is verified by a high-speed dual fluoroscopic imaging system (DFIS).

CLAI patients exhibited earlier Vastus medialis (p < 0.001) and tibialis anterior (p < 0.001) muscle activation during landing. The FE analysis revealed that with laxity in the ATFL, the peak von Mises stress in the fifth metatarsal was 20.74 MPa, while with laxity in the CFL, it was 17.52 MPa. However, when both ligaments were relaxed simultaneously, the peak von Mises stress surged to 21.93 MPa. When the ATFL exhibits laxity, the CFL is subjected to a higher stress of 3.84 MPa. Conversely, when the CFL displays laxity, the ATFL experiences a peak von Mises stress of 2.34 MPa.

This study found that changes in the laxity of the ATFL and the CFL are linked to shifts in metatarsal stress levels, potentially affecting ankle joint stability. These alterations may contribute to the progression towards CLAI in individuals with posterolateral ankle ligament injuries. Additionally, significant muscle activation pattern changes were observed in CLAI patients, suggesting altered neural control strategies post-ankle ligament injury.

Ankle sprains are the second most common sports injury after knee injuries, with about 85% of them affecting the lateral ankle ligaments. These injuries are particularly prevalent in sports like basketball and volleyball.

To investigate the effect of Aquatic therapy as an early rehabilitation protocol for elite athletes with acute lateral ankle sprain grade III on back-to-sport time, dynamic balance, pain, Athletic performance, and muscle power compared to land-based exercise training.

Thirty elite athletes have ankle sprain grade III with sprain onset from 1 to 7 days, their age ranges from 18-30 years old were recruited. All participants are professional athletes; mainly participating in above-head sports such as volleyball and basketball. The patients were randomly allocated into two treatment groups: Group I (control group): 15 patients received a conventional physical therapy program of structured therapeutic exercise program, manual therapy and land-based exercises, in addition to external support, and Group II (Aquatic therapy group): 15 patients received aquatic training. Visual Analog Scale (VAS) was used to measure the pain intensity, while the dynamic balance was measured by the Star Excursion Balance Test. Athletic performance was measured by HOP Tests (Single, Triple, 6-m, and Cross-over hops) aided by the Agility T-Test (ATT) and Illinois Agility Test (IAT). Muscle power was tested by a Single Leg Press. Finally, back to sports time was recorded for each participant in both groups.

There was a significant interaction effect of Aquatic therapy and time for VAS (p < 0.001), single hop (p < 0.001), triple hop (p < 0.001), cross-over hop (p < 0.001), IAT (p = 0.019) and ATT (p < 0.001) of both affected and nonaffected. There was no significant interaction effect of Aquatic therapy and time for 6-MHT of affected (p = 0.923), and nonaffected (p = 0.140). There was a significant main effect of time for all dependent variables (p < 0.001) except for 6-MHT of affected (p = 0.939), nonaffected (p = 0.109), and IAT (p = 0.099). The Star excursion dynamic balance test (SEBT) and Single leg press revealed a significant difference between groups on affected and non-affected sides (p < 0.001*). Lastly and most importantly the back-to-sport time revealed a significant difference in the return-to-sport time in favor of the Aquatic therapy group who returned faster than the control group (p < 0.001*).

Aquatic therapy is more effective than traditional protocols regarding early rehabilitation of acute ankle sprain grade III in Elite professional athletes for reducing pain intensity, improving dynamic balance and athletic performance and power and accelerating their return to sports time. Because aquatic therapy produces better outcomes, it is advised to be included in the rehabilitation programs of athletic patients with acute ankle sprains grade III.

To compare the image quality of virtual noncontrast (VNC) and true noncontrast (TNC) CT images and to evaluate the clinical feasibility of VNC CT images for assessing osteochondral lesions of the talus (OLTs).

Forty-five OLT patients who underwent ankle CT arthrography (CTA) using dual-layer spectral detector CT were enrolled. Reconstruction of VNC and three-dimensional volume rendering images was performed. Afterward, image noise, the signal-to-noise ratio (SNR), and the contrast-to-noise ratio (CNR) were measured. For the subjective evaluation, two board-certified musculoskeletal radiologists [R2-1] assessed spatial resolution, overall image quality, and lesion conspicuity. The accuracy rate for OLT grading was determined in 23 patients who underwent arthroscopic surgery.

While VNC images showed significantly less noise than TNC images, TNC images showed better SNRs and CNRs (p<.01). In the subjective analysis, TNC images showed better overall image quality (p<.001). For the 3D volume rendering images, VNC images scored significantly higher for lesion conspicuity (p<.001). The accuracy rates of CTA and CTA with VNC images for OLT grading were 79.2% and 83.3%, respectively. Regarding confidence level, when CTA and VNC images were evaluated together, the confidence level was significantly higher than that when only CTA images were evaluated (p<.001).

VNC imaging can provide better confidence level of OLT grading and evaluation of the integrity of the subchondral bone plate when combined with conventional CTA without additional radiation dose to the patient. In addition, VNC images-based 3D volume rendering reconstruction would be helpful for preoperative planning in OLT patients.

Ankle sprains are the most frequently occurring musculoskeletal injuries among recreational athletes. Ankle support through bandages following the initial orthotic treatment might be beneficial for rehabilitation purposes. However, the literature is sparse regarding the use of an ankle support directly after the acute phase of an ankle sprain. Therefore, this study investigates the hypothesis that wearing an ankle bandage immediately after an acute ankle sprain improves motor performance, stability and reduces pain. In total, 70 subjects with acute unilateral supination trauma were tested. Subjects were tested five weeks post-injury to assess immediate effects of the ankle bandage. On the testing day, subjects completed rating questionnaires and underwent comprehensive biomechanical assessments. Biomechanical investigations included fine coordination and proprioception tests, single leg stances, the Y-Balance test, and gait analysis. All biomechanical investigations were conducted for the subject's injured leg with and without a bandage (MalleoTrain® Bauerfeind AG, Zeulenroda-Triebes, Germany) and the healthy leg. Results indicated moderate to strong improvements in ankle stability and pain relief while wearing the bandage. Wearing the bandage significantly normalized single leg stance performance (p < 0.001), stance phase duration (p < 0.001), and vertical ground reaction forces during walking (p < 0.05). However, the bandage did not have a clear effect on fine coordination and proprioception. The findings of our study suggest that ankle bandages may play a crucial role in early-stage rehabilitation by enhancing motor performance and reducing pain.