Arthroscopic anatomical reconstruction of lateral collateral ligaments with ligament advanced reinforcement system artificial ligament for chronic ankle instability

BACKGROUND Recently,the use of ligament advanced reinforcement system(LARS)artificial ligament,a new graft which has several unique advantages such as no donor-site morbidity,early recovery and no risk of disease transmission which has been a significant breakthrough for anatomical ligament reconstruction.Growing studies suggested that the special design of the LARS ligament with open fibers in its intra-articular part was believed to be more resistant to torsional fatigue and wearing.However,the safety and efficacy of LARS artificial ligament for ankle joint lateral collateral ankle ligament reconstruction has not been defined to date.AIM To evaluate the clinical results of all-arthroscopic anatomical reconstruction of ankle joint lateral collateral ligaments with the LARS artificial ligament for chronic ankle instability.METHODS Twenty-two patients with chronic lateral instability underwent anatomical reconstruction of the lateral collateral ligaments of ankle with LARS artificial ligament.The visual analogue score(VAS),American Orthopaedic Foot and Ankle Society score(AOFAS score)and Karlsson score were used to evaluate the clinical results before and after surgery.RESULTS A total of 22 patients(22 ankles)were followed up for a mean of 12 mo.All patients reported significant improvement compared to their preoperative status.The mean AOFAS score improved from 42.3±4.9 preoperatively to 90.4±6.7 postoperatively.The mean Karlsson score improved from 38.5±3.2 preoperatively to 90.1±7.8 postoperatively.The mean VAS score improved from 1.9±2.5 preoperatively to 0.8±1.7 postoperatively.CONCLUSION All-arthroscopic anatomical reconstruction of the lateral collateral ligaments with LARS artificial ligament achieved a satisfactory surgical outcome for chronic ankle instability.

Ankle Arthroscopy,Lateral Ligament Repair and Peroneal Tendon Reefing for Chronic Lateral Ankle Instability:The Triad vs Arthroscopy with Ligament Repair

Peroneal tendon and retinacular pathology contributes to chronic lateral ankle instability. The “gold standard” surgical treatment for chronic lateral ankle instability has been the Brostrom-Gould procedure with its modifications. An ankle arthroscopy is an adjuvant procedure to address any intra-articular pathology. We review our results of two study groups. The first group underwent an ankle arthroscopy and a Brostrom-Gould procedure. The second group (triad) underwent an ankle arthroscopy, the Brostrom-Gould procedure and excision of low lying peroneal muscle belly with tightening of the inferior peroneal retinaculum. The triad technique was performed on 97 patients and results compared to 71 ankle arthroscopies with the Brostrom-Gould procedure. The patients were contacted at a mean follow-up time of 30 months for postoperative ACFAS scores, VAS scores, and overall satisfaction. Patients were also asked to report incidence of ankle sprain recurrence. The average postoperative ACFAS hindfoot and ankle score was 92 for the triad group and 89 for the arthroscopic debridement and Brostrom-Gould group. The average overall satisfaction was 98% in the triad group and 91% in the scope and Brostrom group. There were 4 (4.3%) recurrences in the triad group and 12 (17.6%) in the Brostrom-Gould with scope group. Each group had a similar incidence of wound healing complications. Peroneal tendon and retinacular pathology contributes to continued ankle instability and pain. We believe that the triad procedure is superior to the Brostrom-Gould procedure.

Risk factors for chronic ankle instability after first episode of lateral ankle sprain:A retrospective analysis of 362 cases

Background:Chronic ankle instability(CAI) is a common sequela following an acute lateral ankle sprain(LAS).To treat an acture LAS more effectively and efficiently,it is important to identify patients at substantial risk for developing CAI.This study identifies magnetic resonance imaging(MRI) manifestations for predicting CAI development after a first episode of LAS and explores appropriate clinical indications for ordering MRI scans for these patients.Methods:All patients with a first-episode LAS who received plain radiograph and MRI scanning within the first 2 weeks after LAS from December 1,2017 to December 1,2019 were identified.Data were collected using the Cumberland Ankle Instability Tool at final follow-up.Demographic and other related clinical variables,including age,sex,body mass index,and treatment were also recorded.Univariable and multivariable analyses were performed successively to identify risk factors for CAI after first-episode LAS.Results:A total 131 out of 362 patients with a mean follow-up of 3.0± 0.6 years(mean ± SD;2.0—4.1 years) developed CAI after first-episode LAS.According to multivariable regression,development of CAI after first-episode LAS was associated with 5 prognostic factors:age(odds ratio(OR)=0.96,95% confidence interval(95%CI):0.93-1.00,p=0.032);body mass index(OR=1.09,95%CI:1.02-1.17,p=0.009);posterior talofibular ligament injury(OR=2.17,95%CI:1.05-4.48,p=0.035);large bone marrow lesion of the talus(OR=2.69,95%CI:1.30-5.58,p=0.008),and Grade 2 effusion of the tibiotalar joint(OR=2.61,95%CI:1.39-4.89,p=0.003).When patients had at least 1 positive clinical finding in the 10-m walk test,anterior drawer test,or inversion tilt test,they had a 90.2% sensitivity and 77.4% specificity in terms of detecting at least 1 prognostic factor by MRI.Conclusion:MRI scanning is valuable in predicting CAI after first-episode LAS for those patients with at least 1 positive clinical finding in the10-m walk test,anterior drawer test,and inversion tilt test.Further prospective and large-scale studies are necessary for validation.

A lateral ankle sprain during a lateral backward step in badminton:A case report of a televised injury incident

Background:This study presents a kinematic analysis of an acute lateral ankle sprain incurred during a televised badminton match.The kinematics of this injury were compared to those of 19 previously reported cases in the published literature.Methods:Four camera views of an acute lateral ankle sprain incurred during a televised badminton match were synchronized and rendered in3-dimensional animation software.A badminton court with known dimensions was built in a virtual environment,and a skeletal model scaled to the inj ured athlete’s height was used for skeletal matching.The ankle joint angle and angular velocity profiles of this acute injury were compared to the summarized findings from 19 previously reported cases in the published literature.Results:At foot strike,the ankle joint was 2° everted,33° plantarflexed,and 18° internally rotated.Maximum inversion of 114° and internal rotation of 69° was achieved at 0.24 s and 0.20 s after foot strike,respectively.After the foot strike,the ankle joint moved from an initial position of plantarflexion to dorsiflexion-from 33° plantarflexion to 53° dorsiflexion(range=86°).Maximum inversion,dorsiflexion,and internal rotation angular velocity were 1262°/s,961°/s,and 677°/s,respectively,at 0.12 s after foot strike.Conclusion:A forefoot landing posture with a plantarflexed and internally rotated ankle joint configuration could incite an acute lateral ankle sprain injury in badminton.Prevention of lateral ankle sprains in badminton should focus on the control and stability of the ankle joint angle during forefoot landings,especially when the athletes perform a combined lateral and backward step.

Do ankle braces provide similar effects on ankle biomechanical variables in subjects with and without chronic ankle instability during landing?

Purpose:The purpose of this study was to examine effects of a sport version of a semi-rigid ankle brace (ElementTM) and a soft ankle brace (ASO) on ankle biomechanics and ground reaction forces (GRFs) during a drop landing activity in subjects with chronic ankle instability (CAI)compared to healthy subjects with no history of CAI.Methods:Ten healthy subjects and 10 subjects who had multiple ankle sprains participated in the study as the control and unstable subjects,respectively.The CAI subjects were age,body mass index and gender matched with the control subjects.The arch index and ankle functions of the subjects were measured in a subject screening session.During the biomechanical test session,participants performed five trials of drop landing from 0.6 m,wearing no brace ( NB),ElementTM brace and ASO brace.Simultaneous recording of three-dimensional kinematic (240 Hz)and GRF (1200 Hz) data were performed.Results:The CAI subjects had lower ankle functional survey scores.The arch index and deformity results showed greater arch deformity of ElementTM against a static load than in NB and ASO due to greater initial arch position held by the brace.CAI participants had greater eversion velocity than healthy coutrols.The ASO brace reduced the first peak vertical GRF whereas ElementTM increased 2nd peak vertical GRF.ElementTM brace reduced eversion range of motion (ROM) and peak eversion velocity compared to NB and ASO.In addition,ElementTM reduced dorsiflexion ROM and increased peak plantarflexion moment compared to NB and ASO.Conclusion:Results of static arch measurements and dynamic ankle motion suggest that the restrictions offered by both braces are in part due to more dorsiflexed ankle positions at contact,and higher initial arch position and stiffer ankle for ElementTM.

Graft choices for anterolateral ligament knee reconstruction surgery: Current concepts

The anterolateral ligament(ALL)is a primary structure of the anterolateral complex of the knee that contributes to internal rotational stability of the joint.Injury of the ALL is commonly associated with rupture of the anterior cruciate ligament.If left untreated,ALL lesions may lead to residual anterolateral rotational instability of the knee after anterior cruciate ligament reconstruction,which is a common cause of anterior cruciate ligament graft failure.The function of the ALL can be restored by lateral extraarticular tenodesis or anterolateral ligament reconstruction(ALLR).In the lateral extraarticular tenodesis procedure,a strip of the iliotibial band is placed in a non-anatomical position to restrain the internal rotation of the tibia,while in ALLR,a free graft is fixed at the insertion points of the native ALL.Gracilis and semitendinosus grafts have mainly been utilized for ALLR,but other autografts have also been suggested.Furthermore,allografts and synthetic grafts have been applied to minimize donor-site morbidity and maximize the size and strength of the graft.Nevertheless,there has been no strong evidence to fully support one method over another thus far.The present review presents a detailed description of the graft choices for ALLR and the current literature available in regard to the effectiveness and outcomes of published surgical techniques.

Correlation of stress radiographs to injuries associated with lateral ankle instability

BACKGROUND Stress radiographs have demonstrated superior efficacy in the evaluation of ankle instability.AIM To determine if there is a degree of instability evidenced by stress radiographs that is associated with pathology concomitant with ankle ligamentous instability.METHODS A retrospective review of 87 consecutive patients aged 18-74 who had stress radiographs performed at a single institution between 2014 and 2020 was performed.These manual radiographic stress views were then correlated with magnetic resonance imaging and operative findings.RESULTS A statistically significant association was determined for the mean and median stress radiographic values and the presence of peroneal pathology(P=0.008 for tendonitis and P=0.020 for peroneal tendon tears).A significant inverse relationship was found between the presence of an osteochondral defect and increasing degrees of instability(P=0.043).CONCLUSION Although valuable in the clinical evaluation of ankle instability,stress radiographs are not an independent predictor of conditions associated with ankle in-stability.

Clinical and mechanical outcomes in isolated anterior cruciate ligament reconstruction vs additional lateral extra-articular tenodesis or anterolateral ligament reconstruction

BACKGROUND Anterior cruciate ligament(ACL) reconstruction has been a successful treatment for ACL rupture.However ongoing rotational instability can be an issue.Several surgical techniques have been recommended to overcome this including lateral extra-articular tenodesis(LET) and more recently anterolateral ligament reconstruction(ALLR).AIM To compare the clinical outcomes following ACL reconstruction(ACLR) alone or ACLR with either LET or ALLR.METHODS A systematic review was conducted by means of four databases(MEDLINE,EMBASE,Cochrane and Clinical.Trials.Gov),and the Reference Citaion Analysis(https://www.referencecitationanalysis.com/) to identify all studies investigating either or both of LET and ALLR.The Critical Appraisal Skills Programme checklist for cohort studies was employed for critical appraisal and evaluation of all twenty-four studies which met the inclusion criteria.RESULTS Pooled meta-analyses illustrated that ACLR with additional LET or ALLR results in improved pivot shift test scores,compared to isolated ACLR.There was no statistically significant difference in International Knee Documentation Committee(IKDC) clinical scores with addition of either LET or ALLR.ACL re-rupture rates were compared between LET and ALLR techniques.There was a statistically significant difference between techniques,with a 1.14% rupture rate in ACLR +ALLR,and 4.03% rupture rate in ACLR + LET.Isolated ACLR re-rupture rates were 12.59%,significantly higher than when augmented with either ALLR or LET(P < 0.0001 for both groups).There were no statistical differences in pivot shift test or IKDC scores between LET and ALLR techniques.CONCLUSION This meta-analysis has found that use of either LET or ALLR in addition to ACLR results in improved mechanical outcomes suggesting surgeons should consider augmenting ACLR with an extra-articular procedure in patients with rotatory instability.Furthermore,both anterolateral extra articular procedures in addition to ACLR lead to reduced ACL re-rupture rates compared to isolated ACLR.Moreover,ALLR results in reduced ACL re-rupture rates,compared to LET.More research is needed to compare the two respective extra-articular procedures.

Clinical study on Tuina plus physical agents for lateral collateral ligament injury of ankle in gymnasts

Objective To compare the efficacy of Tuina(Chinese therapeutic massage)plus physical agents and physical agents alone for lateral collateral ligament injury of ankle in gymnasts,and to explore the feasibility of Tuina for injury intervention in competitive athletes.Methods A total of 64 gymnasts with types Ⅰ-Ⅱ lateral collateral ligament injury of ankle were selected and divided into a control group and an observation group according to a full analysis set based on the intention-to-treat principle,with 32 cases in each group.Patients in the control group received ultrasound and microwave treatment,while those in the observation group received additional Tuina manipulations.The efficacy was evaluated by total effective rate,visual analog scale(VAS)score,and American Orthopedic Foot and Ankle Society ankle-hindfoot scale(AOFAS-AHS)score.Results The total effective rate was 96.9% in the observation group and 90.6% in the control group.There was no statistical difference in the total effective rate between the two groups(P>0.05).The markedly effective rate was 75.0% in the observation group and 46.9% in the control group.The markedly effective rate in the observation group was higher than that in the control group(P<0.05).After treatment,the VAS scores of both groups showed a downward trend,and there were statistical differences between different treatment time points in the same group(P<0.05).After one and three months of treatment,the VAS scores of the observation group were lower than those of the control group(P<0.05).There were statistical differences in the AOFAS-AHS score before and after treatment within the same group(P<0.05).After one month of treatment,there was no statistical difference in the AOFAS-AHS score between the two groups(P>0.05).After three months of treatment,the AOFAS-AHS score in the observation group was higher than that in the control group,indicating statistical significance(P<0.05).There was an interaction between time and group(P<0.05).Conclusion Tuina plus physical agents can improve the symptoms of lateral collateral ligament injury of ankle in gymnasts.This combined treatment is superior to physical agents alone in relieving pain and improving joint functions.Therefore,Tuina plus physical agents can be used as a treatment for lateral collateral ligament injury of ankle in gymnasts.

Management and prevention of acute and chronic lateral ankle instability in athletic patient populations

Acute and chronic lateral ankle instability are common in high-demand patient populations. If not managed appropriately, patients may experience recurrent instability, chronic pain, osteochondral lesions of the talus, premature osteoarthritis, and other significantlong-term disability. Certain populations, including young athletes, military personnel and those involved in frequent running, jumping, and cutting motions, are at increased risk. Proposed risk factors include prior ankle sprain, elevated body weight or body mass index, female gender, neuromuscular deficits, postural imbalance, foot/ankle malalignment, and exposure to at-risk athletic activity. Prompt, accurate diagnosis is crucial, and evidence-based, functional rehabilitation regimens have a proven track record in returning active patients to work and sport. When patients fail to improve with physical therapy and external bracing, multiple surgical techniques have been described with reliable results, including both anatomic and nonanatomic reconstructive methods. Anatomic repair of the lateral ligamentous complex remains the gold standard for recurrent ankle instability, and it effectively restores native ankle anatomy and joint kinematics while preserving physiologic ankle and subtalar motion. Further preventative measures may minimize the risk of ankle instability in athletic cohorts, including prophylactic bracing and combined neuromuscular and proprioceptive training programs. These interventions have demonstrated benefit in patients at heightened risk for lateral ankle sprain and allow active cohorts to return to full activity without adversely affecting athletic performance.

Anatomy of the lateral ligaments of the rectum: A controversial point of view

The existence and composition of the lateral ligaments of the rectum (LLR) are still the subjects of anatomical confusion and surgical misconception up to now. Since Miles proposed abdominoperineal excision as radical surgery for rectal cancer, the identification by "hooking them on the finger" has been accepted by many surgeons with no doubt; clamping, dividing and ligating are considered to be essential procedures in mobilization of the rectum in many surgical textbooks. But in cadaveric studies, many anatomists could not find LLR described by the textbooks, and more and more surgeons also failed to find LLR during the proctectomy according to the principle of total mesorectal excision. The anatomy of LLR has diverse descriptions in literatures. According to our clinical observations, the traditional anatomical structures of LLR do exist; LLR are constant dense connective bundles which are located in either lateral side of the lower part of the rectum, run between rectal visceral fascia and pelvic parietal fascia above the levator ani, and covered by superior fascia of pelvic diaphragm. They are pathways of blood vessels and nerve fibers toward the rectum and lymphatic vessels from the lower rectum toward the iliac lymph nodes.

Delayed reconstruction of lateral complex structures of the ankle

Lateral ankle instability is one of the most common and well-recognized conditions presenting to foot and ankle surgeons.It may exist as an isolated entity or in conjunction with other concomitant pathology,making it important to appropriately diagnose and identify other conditions that may need to be addressed as part of treatment.These associated conditions may be a source of chronic pain,even when the instability has been appropriately treated,or may lead to failure of treatment by predisposing the patient to ankle inversion injuries.The primary goal of this editorial is to provide a brief summary of the common techniques used in the delayed reconstruction of lateral ankle ligamentous injuries and present a method we have successfully employed for over 15 years.We will also briefly discuss the diagnosis and treatment of the more common associated conditions,which are important to identify to achieve satisfactory results for the patient.We present the outcomes of 250 consecutive reconstructions performed over the last 10 years and describe our operative technique for addressing lateral ankle ligamentous injuries.

Comparison of surgical intervention with functional treatment for acute ruptures of lateral ankle ligmant:a meta-analysis

Objective:To compare the effect of surgical intervention on functional treatment.Methods: By searching the MEDLINE(1966 to October 2011),EMBASE(1980 to October 2011),the Chinese Biomedical Database Databases(1980 to October 2011),a total of 9 related RCT studies comparing surgical intervention with functional treatment were included in our study.RevMan software was taken to analyze the data.Results:These 9 studies Involved a total of 1 268 mostly young adults,including 580 patients with surgical treatment and 688 patients with functional treatment.The results showed the stability of ankle activity in surgical treatment group was better than that in functional treatment group,with the OR and 95%CI of 0.72(0.52-0.99).No significant difference was found in the recurrence of the surgical and functional group.However, the movement disorder in the surgical treatment suggested increased risk than that in functional group,with the OR and 95%CI of 2 39(0.98-5.85).Surgical group found more complication than the function group,such as deep vein thrombosis,deep venous thrombosis,tenderness of scar and sensory loss.Conclusions:In conclusion,our finding showed that surgical treatment could gain better efficacy than functional treatment,but may bring more complication.Therefore,further large sample size RCT is warranted.

The Effect of Percutaneous Screw Fixation of Lateral Malleolus on Ankle Fracture Healing and Function

Purpose: To measure the effectiveness of using percutaneous intramedullary screw fixation of the lateral malleolus fracture on the healing and functional outcome of ankle fracture. Materials and methods: Forty-six patients with Weber A and low Weber B displaced lateral malleolus fractures who underwent closed reduction and percutaneous internal fixation with an intramedullary, fully threaded, screw were retrospectively reviewed. A 3.5-mm, fully threaded, selftapping bone screw (stainless steel from Pelvic Set Synthes). The length of the screw varies between 100 mm and 120 mm, depending on the fracture location and pattern. Results: All fractures united within an average time to union of 8.2 weeks. In all patients the average time to full weight bearing was 6.8 weeks, whereas that in patients with isolated lateral malleolus fractures was 4.5 weeks. There were no deep wound infections or complaints of painful hardware. At latest follow-up, functional results were excellent in, 25 patients (54.3%) good in 20 (43.5%), fair in (2.2%). Conclusion: If reduction of the lateral malleolus fracture can be obtained in a closed fashion (with the aid of an image x-ray intensifier), we believe that fixation may be performed with an axial screw percutaneously. This technique is quick, safe and easy to do with less complication.

Anatomical Reconsideration of the Lateral Collateral Ligament in the Human Knee: Anatomical Observation and Literature Review

In the published literature as well as in the most commonly used textbooks, the lateral collateral ligament (LCL) is described as having 1 attachment at the lateral epicondyle of the femur and another at the head of the fibula. In this article, we reconsider the attachments, the length of the LCL, and the tissues surrounding the LCL by presenting our anatomical observations and by reviewing the literature. Our results have shown that the LCL is not only attached to the lower part of the lateral epicondyle of the femur, but also extends to the upper part of the lateral epicondyle. The attachment of the LCL on the fibula is enclosed by 2 insertion points of the biceps femoris tendon. The average length of the LCL in 71 knees was 51.4 mm. There is an “incomplete gap” on the LCL that is interrupted under the tendon of the biceps femoris.

Effect of a combined inversion and plantarflexion surface on ankle kinematics and EMG activities in landing

Purpose： The purpose of this study was to examine the effects of landing kinematics and electromyographic （EMG） activities of medial gastrocnemius on a combined inversion and plantarflexion surface on the ankle （MG）, peroneus longus （PL）, and tibialis anterior （TA） muscles. Methods： Twelve recreational athletes performed five drop landings from an overhead bar of 30 cm height on to three surfaces： a flat surface, a 25° inversion surface, and a combined surface of 25° inversion and 25° plantarflexion. The kinematic variables and integrated EMG （IEMG） of the three muscles were assessed using a one-way repeated measures ANOVA and a 3 × 3 （surface × muscle） ANOVA, respectively （p 〈 0.05）. Results： The IEMG results showed a significant muscle by surface interaction. The flat surface induced higher TA activity than the two tilted surfaces. The inverted surface produced significantly higher inversion peak angle and velocity than the flat surface, but similar PL activity across the surfaces. The MG IEMG, ankle plantarflexion angle, and inversion range of motion were significantly higher for the combined surface compared to the inverted surface. Conclusion： These findings suggest that compared to the inversion surface, the combined plantarflexion and inversion surface seems to provide a more unstable surface condition for lateral ankle sprains during landing.

Ankle Arthroscopy: A Complimentary Adjunct in the Diagnosis and Management of Ankle Fractures

Ankle fractures are one of the most common injuries treated by orthopaedic surgeons. A minority of patients with ankle fractures go on to develop persistent pain following anatomical reduction. These sequelae may arise as a result of untreated ligamentous or chondral injuries. This study aims to correlate acute arthroscopic ankle findings with the Lauge-Hansen fracture pattern classification. We further aim to compare subjective functional outcomes at least one year following surgery between patients who have received Open Reduction and Internal Fixation (ORIF) alone, versus ORIF plus arthroscopy. This is a retrospective case series of patients who have undergone ankle fracture ORIF +/- arthroscopy from July 2014 to July 2017 inclusive. Each patient’s presenting radiograph was classified according to the Lauge-Hansen ankle fracture classification with subsequent correlation to intra-operative arthroscopic findings. Functional outcome at a minimum of one year was evaluated with the American Academy of Orthopaedic Surgeons (AAOS) metric. Twenty two patients underwent ankle ORIF plus arthroscopy (Group A) with a further 26 patients receiving ORIF alone (Group B). 1 in 3 supination-external-rotation type II (SER II) injuries possessed a concomitant syndesmosis injury or osteochondral lesion (OCL) on arthroscopy. 1 in 3 patients with an SER IV injury had an osteochondral lesion. The mean AAOS score achieved for Group A was 89.6 (±7.9) with the mean score for Group B being 82.0 (±13.7). In conclusion, ankle arthroscopy aids the diagnosis and treatment of ligamentous and osteochondral injuries not evident on plain film with subsequent superior short-term outcomes.

Lateral femoral tunnel preparation and graft fixation for anterior cruciate ligament reconstruction–A discussion

This article provides a discussion and commentary around the recent advances in arthroscopic anterior cruciate ligament reconstruction(ACLR),with a focus on the aspects of lateral femoral tunnel preparation and graft fixation techniques.The paper explores and comments on a recently published review by Dai et al,titled"Research progress on preparation of lateral femoral tunnel and graft fixation in ACLR",while providing insight into its relevance within the field of ACLR,and recommendations for future research.

Biomechanics of ankle giving way:A case report of accidental ankle giving way during the drop landing test

Background:Several case studies observed that the lateral ankle sprain resulted from a sudden increase in ankle inversion accompanied by internal rotation.However,without sufficient ankle kinetics and muscle activity information in the literature,the detailed mechanism of ankle sprain is still unrevealed.The purpose of our case report is to present 2 accidental ankle giving way incidents for participants with chronic ankle instability(CAI)and compare to their normal trials with data of kinematics,kinetics,and electromyography(EMG).Case description:Two young female participants accidentally experienced the ankle giving way when landing on a 25°lateral-tilted force plate.3 D kinematics,kinetics,and muscle activity were recorded for the lower extremity.Qualitative comparisons were made between the giving way trials and normal trials for joint angles,angular velocities,moments,centers of pressure and EMG linear envelopes.Results:One participant’s giving way trial displayed increased ankle inversion and internal rotation angles in the pre-landing phase and at initial contact compared to her normal trials.Another participant’s giving way trial exhibited greater hip abduction angles and delayed activation of the peroneus longus muscle in the pre-landing phase versus her normal trials.Conclusion:A vulnerable ankle position(i.e.,more inverted and internally rotated),and a late activation of peroneus activity in the pre-landing phase could result in the ankle giving way or even sprains.A neutral ankle position and early activation of ankle evertors before landing may be helpful in preventing ankle sprains.

Diagnosing syndesmotic instability in ankle fractures

The precise diagnosis of distal tibiofibular syndesmotic ligament injury is challenging and a distinction should be made between syndesmotic ligament disruption and real syndesmotic instability.This article summarizes the available evidence in the light of the author’s opinion.Pre-operative radiographic assessment,standard radiographs,computed tomography scanning and magnetic resonance imaging are of limited value in detecting syndesmotic instability in acute ankle fractures but can be helpful in planning.Intra-operative stress testing,in the sagittal,coronal or exorotation direction,is more reliable in the diagnosis of syndesmotic instability of rotational ankle fractures.The Hook or Cotton test is more reliable than the exorotation stress test.The lateral view is more reliable than the AP mortise view because of the larger displacement in this direction.When the Hook test is used the force should be applied in the sagittal direction.A force of 100 N applied to the fibula seems to be appropriate.In the case of an unstable joint requiring syndesmotic stabilisation,the tibiofibular clear space would exceed 5 mm on the lateral stress test.When the surgeon is able to perform an ankle arthroscopy this technique is useful to detect syndesmotic injury and can guide anatomic reduction of the syndesmosis.Many guidelines formulated in this article are based on biomechanical and cadaveric studies and clinical correlation has to be established.