Ultrasound-Guided Ankle Lateral Ligament Stabilization
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Purpose of Review
Ultrasound (US) is an increasingly popular imaging modality currently used both in clinics and operating rooms. The purpose of this review is to appraise literature describing traditional lateral ankle stabilization techniques and discuss potential advantages of US-guided ankle lateral ligament stabilization. In addition, albeit limited, we will describe our experiences in perfecting this technique.
To date, the modified open Broström-Gould technique remains as the gold standard surgical treatment for chronic ankle instability (CAI). In the past decade, modifications of this technique have been done, from a combination of arthroscopic and open procedure to an all-inside arthroscopic technique with a goal of minimizing wound complications, better outcomes, and earlier return to activity. Recently, the use of US as an adjunct to surgical procedures has gained popularity and several novel techniques have been described. The use of US in lateral ankle stabilization could allow accurate placement of the suture anchor at the anatomical attachment of the anterior talofibular ligament (ATFL) without iatrogenic damage to the neurovascular structures such as anterolateral malleolar artery, superficial peroneal nerve, and sural nerve.
In summary, the use of US in ankle lateral ligament stabilization is a promising new micro-invasive technique. The theoretical advantages of US-guided ankle lateral ligament stabilization include direct visualization of desired anatomical landmarks and structures which could increase accuracy, decrease iatrogenic neurovascular damage, minimize wound complications, and improve outcomes.
KeywordsUltrasound Ultrasound-guided surgery Chronic ankle instability Lateral ligament stabilization
Compliance with Ethical Standards
Conflict of Interest
Soichi Hattori, M.D., Carlo Antonio Alvarez, M.D., Stephen Canton, M.D., Kentaro Onishi, D.O., and Macalus V. Hogan, M.D. declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.• Porter D, Kamman K. Chronic lateral ankle instability: open surgical management. Foot and Ankle Clin N Am. 2018;23:539–54 Anatomic ligament repair/reconstruction with patient satisfaction rates more than 90%, the most popularized technique, the modified Brostrom is routinely considered the first-line treatment of CLAI. We prefer the open approach with the use of bone tunnels with an absorbable suture (BT) rather than suture anchors (SAs). A recent level II prospective cohort study comparing BT and SA techniques in 81 patients undergoing the modified Brostrom procedure demonstrated similar outcomes.34 The mean Karlsson scores, American Orthopedic Foot and Ankle Society scores, anterior talar translation, and talar tilt improved significantly with both procedures after intervention. There were no significant differences between the two cohorts, yet there was a clear trend in preoperative scores favoring the SA group over the BT group, suggesting the BT patients had more attenuated ligaments preoperatively. Associated pathology (defined as synovitis, OCL of talus, anterior bony impingement, loose body, and ossicles at the lateral malleolus) occurred in 53% of BT patients and 63% of SA patients. SA displacement, breakage, and pullout have all been reported in the literature35; but these complications that are unique to the SA technique were not investigated in this study. Indeed, one disadvantage of SAs is the unique complications that are inherent to its use. For these reasons, as well as the cost of SA and the ease of using BT, we advocate the use of bone tunnels for our open approach BLAR. In overview, the BLAR operative technique begins with diagnostic arthroscopy using anterolateral and anteromedial portals (and other auxiliary portals as needed) and after appropriately evaluating for and treating intra-articular pathology, finishes with an open modified Brostrom ligament reconstruction using bone tunnels. Arthroscopy time should be minimized to limit soft tissue edema and induration. CrossRefGoogle Scholar
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- 4.•• Radwan A, Bakowski J, Dew S, Greenwald B, Hyde E, Webber N. Effectiveness of ultrasonography in diagnosing chronic lateral ankle instability: a systematic review. Int J Sports Phys Ther. 2016;11:164–74 The purpose of this systematic review was to investigate the effectiveness of ultrasonography in diagnosing CAI, in comparison with other diagnostic tools. Methods: articles published between the years 2000–2015, and articles that were peer reviewed and published in the English language. Databases searched: CINAHL, PubMed, Medline, Medline Plus, Science Direct, OVID, Cochrane, and EBSCO. Titles and abstracts of the 1,420 articles were screened for the inclusion criteria by two independent raters, with discrepancies solved by a third rater. The modified 14-point Quality Assessment of Diagnostic Accuracy Studies (QUADAS) scale was used to assess methodological quality of included articles. Results: Six high quality articles were included in this systematic review, as indicated by high scores on the QUADAS scale, ranging from 10 to 13. Sensitivity of US ranged from: 84.6–100%, specificity of US ranged from: 90.9–100% and accuracy ranged from: 87–90.9%. The results of the included studies suggest that US is able to accurately differentiate between the grades of ankle sprains and between a lax ligament, torn ligament, thick ligament, absorbed ligament and a non-union avulsion fracture. These findings indicate that US is a reliable method for diagnosing CAI, and that US is able to classify the degree of instability. Conclusion: Researchers found that US is effective, reliable, and accurate in the diagnosis of CAI. Clinical Implications: US would allow for earlier diagnosis, which could increase the quality of care as well as decrease the number of outpatient visits. This could lead to improvement in treatment plans, goals and rehabilitation outcomes. level of Evidence: 1a.PubMedPubMedCentralGoogle Scholar
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- 35.• Chavez J, Hattori S, et al. The use of ultrasonography during minimally invasive Achilles tendon repair to avoid sural nerve injury. J Med Ultrason. 2019. https://doi.org/10.1007/s10396-019-00951-5Four patients with Achilles tendon ruptures underwent minimally invasive repair in our institution by the same surgeon. With the patients positioned prone under general endotracheal anesthesia, a 3-cm transverse incision was made about 1 cm proximal to the rupture site. A Percutaneous Achilles Repair System (PARS; Arthrex®, Florida, USA) jig was slid within the paratenon. With a sterile sleeve covering the transducer (12 MHz), a mobile ultrasound machine (VenueTM50, GE Healthcare, Tokyo, Japan) was used to avoid the neurovascular bundle each time a needle passed through the lateral side of the tendon. The sutures were all retrieved as the jig was pulled out andthe tendon ends were approximated with the foot in plantarflexion. The procedure was well tolerated by all patients, with no complaints pointing to sural nerve injury such as sensory disturbance and pain throughout their respective follow up periods. The incision sites all healed well without any wound complications such as dehiscence or local infection. Minimally invasive Achilles tendon repair continues to be accompanied by a risk of iatrogenic sural nerve injury despite the employment of measures to consciously protect the sural nerve during repair. Some authors have recommended exposure and visualization of the sural nerve during repair to minimize injury by being able to avoid it with a certain degree of confidence. Others have advocated performing the procedure just under local anesthesia to facilitate a wide-awake surgery so that the patient can generate feedback if any neural disturbance was felt during puncture or infiltration. We have shown that ultrasonography can be used in order to have indirect but real-time visualization during minimally invasive Achilles tendon repair. This can be achieved with the patient comfortable under general or spinal anesthesia, without having to ask feedback regarding neural disturbances throughout the surgery. This also avoids additional incisions and soft tissue trauma just to directly visualize the sural nerve in order to avoid it. Under ultrasound guidance, it was ensured that the needle was always deep to sural nerve each time it passed through the lateral side of the Achilles tendon. With these encouraging results, we highly recommend this method to avoid iatrogenic sural nerve injury during minimally invasive repair of the Achilles tendon. PubMedCrossRefGoogle Scholar
- 38.• Cao S, Wang C, Xi M, Xu W, Huang J, Zhang C. Imaging diagnosis for chronic lateral ankle injury: a systematic review with meta-analysis. J Orthop Surg Res. 2018;13:159 This systemic review will explore the effectiveness of different imaging techniques in diagnosing chronic lateral ankle ligament injury. Methods: Relative studies were retrieved after searching 3 databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trails). Eligible studies were summarized. Data were extracted to calculate pooled sensitivity and specificity of magnetic resonance imaging (MRI), ultrasonography (US), stress radiography, and arthrography. Results: Fifteen studies met our inclusion and exclusion criteria. A total of 695 participants were included. The pooled sensitivities in diagnosing chronic ATFL injury were 0.83 [0.78, 0.87] for MRI, 0.99 [0.96, 1.00] for US, and 0.81 [0.68, 0.90] for stress radiography. The pooled specificities in diagnosing chronic ATFL injury were 0.79 [0.69, 0.87] for MRI, 0.91 [0.82, 0.97] for US, and 0.92 [0.79, 0.98] for stress radiography. The pooled sensitivities in diagnosing chronic CFL injury were 0.56 [0.46, 0.66] for MRI, 0.94 [0.85, 0.98] for US, and 0.90 [0.73, 0.98] for arthrography. The pooled specificities in diagnosing chronic CFL injury were 0.88 [0.82, 0.93] for MRI, 0.91 [0.80, 0.97] for US, and 0.90 [0.77, 0.97] for arthrography. Conclusion: This systematic review with meta-analysis investigated the accuracy of imaging for the diagnosis of chronic lateral ankle ligament injury. Ultrasound manifested high diagnostic accuracy in diagnosing chronic lateral ankle ligament injury. Clinicians should be aware of the limitations of MRI in detecting chronic CFL injuries. PubMedPubMedCentralCrossRefGoogle Scholar
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- 40.• Poggio D, Claret G, et al. Correlation between visual inspection and ultrasonography to identify the distal branches of superficial peroneal nerves: a cadaveric study. Foot Ankle Surg. 2016;55:492–5 The anatomy of the superficial peroneal nerve (SPN) and, more precisely, of the distal branches of the SPN at the ankle has attracted interest owing to the possibility of injury when performing ankle arthroscopy. The anterolateral portal is one of the most commonly used portals in ankle arthroscopy, and the intermediate dorsal cutaneous nerve can easily be injured during portal placement. The purpose of the present study was to assess whether visual inspection and palpation of the cutaneous nerves at the ankle differed from examination with ultrasonography and whether the 2 examination techniques correlated with the anatomic location of the SPN, which was verified by cadaver dissection. First, visual examination and palpation was performed to identify the SPN, after which 12 cadaver legs from separate specimens were examined with ultrasonography to mark the course of the SPN. We then measured the distance between the nerve as identified with gross visualization/palpation and ultrasound examination, and compared these with the precise location determined by anatomic dissection. The use of ultrasonography to determine the course of the SPN was good or excellent in 11 of the 12 legs (91.7%) studied. In contrast, gross visualization/palpation was good or excellent in 4 legs (33.3%). Excellent agreement was observed between the ultrasound markings and the anatomic dissection results. However, the visual examination poorly identified the course and the anatomic variations of the nerve branches evidenced in the anatomic dissection. From these findings in cadaver specimens, ultrasound identification of the SPN and its branches is likely preferable to gross visualization/palpation before placement of the anterolateral arthroscopic portal to the ankle. CrossRefGoogle Scholar
- 42.•• Teramoto A, Shoji H, et al. The distal margin of the lateral malleolus visible under ankle arthroscopy from the anteromedial portal, is separate from the ATFL attachment site of the fibula: a cadaver study. J Orthop Surg Res. 2018;23:5655 The purpose of this study was to evaluate the relationship between the lateral malleolus view under ankle arthroscopy and the anterior talofibular ligament (ATFL) attachment site. Methods: Seven normal ankles from Thiel-embalmed cadavers were investigated. Ankle arthroscopy was performed using a 2.7-mm-diameter, 30-degree, oblique-viewing endoscope. An antero-medial portal (AM), a medial midline portal (MML), and an antero-central portal (AC) were created in order, and the ankle arthroscope was inserted. The lateral malleolus was visualized as distally as possible, and the site that appeared to be the distal margin was marked with a 1.5-mm-diameter K-wire. Visualization with arthroscopy was carried out from all portals to mark the distal margin, and the ankle was subsequently exposed to directly measure the distance from the center of the ATFL attachment site at the fibula to each marking. Results: The distances from the ATFL attachment site to the markings made under arthroscopy from the AM, MML, and AC portals were 10.4 ± 2.6 mm, 7.4 ± 1.9 mm, and 7.3 ± 1.9 mm, respectively. Compared to markings made from the MML or AC portal, the marking made from the AM portal was significantly further away from the ATFL attachment site. Conclusions: A typical ankle arthroscopy portal may not allow complete visualization of the tip of the lateral malleolus, indicating that it may not be feasible to thoroughly observe the ATFL attachment site. It is necessary to perform arthroscopic surgeries with the understanding that the distal margin of the lateral malleolus that appears under ankle arthroscopy is 7e10 mm proximal to the ATFL attachment site. Google Scholar
- 43.•• Hattori S, Kumai T, Ohuchi H. Ultrasound-guided repair of anterior talofibular ligament: anatomical accuracy of anchor placement. Non-inferiority. Abstract. 2019. The 31st Annual Meeting of the Japanese Society of Orthopedic Ultrasonics. The purpose of this study was to evaluate the accuracy of anchor placement in ultrasound-guided anterior talofibular ligament repair (USG ATFLR). Method: We included those underwent open ATFLR and those with USG ATFLR. The distance between the distal anchor and the fibular obscure tubercle (FOT) in 3DCT was measured. We considered that the distance of USG ATFLR would be non-inferior to open ATFLR within 5 mm. Result: We had 11 cases of open ATFLR and 10 USG ATFLR. The mean distance between anchor and FOT was 6.0 ± 2.7 mm in open ATFLR and 7.4 ± 2.5 mm in USG ATFLR respectively. The mean differences of two techniques were − 1.5 mm (95% confidence interval 1.0 to − 3.9). The CI was smaller than the non-inferiority margin (5 mm). Conclusion: Anchor placement under USG ATFLR can be anatomically accurate. Google Scholar
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- 46.• Kenmochi M, Sasaki S, Fujisaki K, Yusuke O, Kotani A, Ichimura S. A new classification of anterior talofibular ligament injuries based on ultrasonography findings. J Orthop Surg Res. 2016;21:770e–78 This study aimed to assess the treatment outcomes of lateral ankle ligament injuries using a new classification for ATFL injuries based on US findings. Methods: A total of 140 acute lateral ankle ligament injuries in 132 patients (46 men, 86 women) treated non-operatively were evaluated retrospectively. The average age of the patients was 17.8 years (range, 7–57 years). Patients with a complaint of lateral ankle injury were examined using US, and the anterior talofibular ligament damage was classified into 5 types depending on the type of the injury. The treat ment method was selected based on the ultrasonographic classification, and the clinical results were assessed by original evaluation and compared between treatment methods and classification types. Results: A Good or Excellent treatment result was obtained in 133 out of 140 injuries (95.0%). Significant differences were observed in the distribution of treatment methods by injury type (P< 0.001), and the distribution of outcomes was significantly different from the uniform distribution (P< 0.001). Our findings demonstrate that the ultrasonographic classification proposed in this study can be used to determine the appropriate treatment resulting in good outcomes for all types of anterior talofibular ligament damage. Conclusion: Visualization of injured ligaments using US may introduce a novel approach of rating and treating ligament injuries. Google Scholar
- 47.• Gosselin M, Haynes J, et al. The arterial anatomy of the lateral ligament complex of the ankle: a cadaveric study. Am J Sports Med. 2018:1–6. https://doi.org/10.1177/0363546518808060The purpose of this study was to define the vascular anatomy of the lateral ligament complex of the ankle. Methods: Thirty pairs of cadaveric specimens (60 total legs) were amputated below the knee. India ink, followed by Ward blue latex, was injected into the peroneal, anterior tibial, and posterior tibial arteries to identify the vascular supply of the lateral ligaments of the ankle. Chemical debridement was performed with 8.0% sodium hypochlorite to remove the soft tissues, leaving casts of the vascular anatomy intact. The vascular supply to the lateral ligament complex was then evaluated and recorded. Results: The vascular supply to the lateral ankle ligaments was characterized in 56 specimens: 52 (92.9%) had arterial supply with an origin from the perforating anterior branch of the peroneal artery; 51 (91.1%), from the posterior branch of the peroneal artery; 29 (51.8%), from the lateral tarsal branch of the dorsalis pedis; and 12 (21.4%), from the posterior tibial artery. The anterior branch of the peroneal artery was the dominant vascular supply in 39 specimens (69.6%). Conclusion: There are 4 separate sources of extraosseous blood supply to the lateral ligaments of the ankle. In all specimens, the anterior talofibular ligament was supplied by the anterior branch of the peroneal artery and/or the lateral tarsal artery of the dorsalis pedis, while the posterior talofibular ligament was supplied by the posterior branch of the peroneal artery and/or the posterior tibial artery. The calcaneofibular ligament received variable contributions from the anterior and posterior branches of the peroneal artery, with few specimens receiving a contribution from the lateral tarsal or posterior tibial arteries. Clinical Relevance: Understanding the vascular anatomy of the lateral ligament complex is beneficial when considering surgical management and may provide insight into factors that lead to chronic instability. PubMedCrossRefPubMedCentralGoogle Scholar
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- 49.• Hattori S, Nimura A, Koyoma M, Tsutsumi M, Amaha K, Ohuchi H, et al. Dorsiflexion is more feasible than plantar flexion in ultrasound evaluation of the calcaneofibular ligament: a combination study of ultrasound and cadaver. Knee Surg Sports Traumatol Arthrosc. 2019. https://doi.org/10.1007/s00167-019-05630-zPurpose Ultrasound (US) is a valuable tool for the evaluation of chronic lateral instability of the ankle; however, the feasibility of US for calcaneofibular ligament (CFL) assessment remains unknown. This study aimed to depict and compare CFL on US in various ankle positions to determine the optimal method for evaluating CFL with US and to interpret US findings using cadaveric specimens. Methods The US study included 43 ankles of 25 healthy individuals. The CFL was scanned with US in 20° plantar flexion, neutral position, 20° dorsiflexion, and maximum dorsiflexion. The distances between fibula and CFL were compared. The cadaveric study included macroscopic qualitative observation of the dynamic change of CFL in 7 ankles and quantitative observation of the directions of CFL and footprints in 17 ankles. Results In the US study, the mean distance (mm) between fibula and CFL was 7.3 ± 1.3 in 20° plantar flexion, 6.7 ± 1.6 in neutral position, 4.3 ± 2.5 in 20° dorsiflexion and 3.1 ± 2.1 in maximum dorsiflexion. The more dorsiflexed the ankle was, the shorter the distance between fibula and CFL was (Jonckheere’s trend testp< 0.001). In the cadaveric study, the CFL fibers were aligned parallel between the mid-substance and the fibular attachment in maximum dorsiflexion, whilst CFL was reflected and rotated in plantar flexion. Conclusions The whole length of the CFL, including its fibular attachment, is more likely to be visualized with US in dorsiflexion than in plantar flexion due to the direction of the CFL at the fibular attachment, which is parallel with the mid-substance in maximum dorsiflexion. Level of evidence IV.
- 51.•• Vega J, Guelfi M, Malagelada F, Pena F, Dalmau-Pastor M. Arthroscopic all-inside anterior talofibular ligament repair through a three-portal and no-ankle-distraction technique. JBJS Essent Surg Tech. 2018;8(3):e25. https://doi.org/10.2106/JBJS.ST.18.00026Arthroscopic treatment of ankle instability is an emerging field attracting increased interest among surgeons. The arthroscopic all-inside ATFL repair allows the surgeon to explore the ankle joint, treat concomitant pathology when encountered, and reattach the injured ATFL to its fibular anatomical location. The aim of this article is to describe the arthroscopic all-inside ATFL repair through a 3-portal no-ankle-distraction technique. Description: after patient positioning, anteromedial and anterolateral portals are created. An accessory anterolateral portal is created just anterior to the fibula and about 1 cm proximal to the tip of the lateral malleolus. The arthroscope is introduced through the anteromedial portal, and the instruments are introduced through the anterolateral portal. Recognition of the ligament and evaluation of the ligament tear with a probe are required. The footprint for the fibular attachment of the ATFL is debrided. The ligament is penetrated with a suture passer. A nitinol loop is pushed and then is pulled out through the accessory portal. The nitinol wire is replaced by a double high-resistance suture.The limbs of the suture located in the accessory portal are passed through the anterolateral portal. Next, one or both limbs of the suture are passed through the loop suture. Pulling of the suture limbs introduces the loop into the joint and the ligament is grasped by the suture. The tunnel for the anchor is drilled. The knotless anchor is loaded with the suture, and the anchor and suture are introduced with the ankle in dorsiflexion and valgus. Postoperatively, the ankle is immobilized with a removable walking boot for 4 weeks. Once use of the walking boot is discontinued, physical therapy is started. Rationale: The described technique has the advantage of being done with a minimally invasive approach and providing an anatomical repair of the ligament. Concomitant intra-articular pathology can be addressed during the procedure through the same arthroscopic approaches. Early rehabilitation and the lack of intra-articular knots areadditional benefits of the technique. CrossRefPubMedPubMedCentralGoogle Scholar
- 52.• Takao M, Matsui K, et al. Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle. Knee Surg Sports Traumatol Arthrosc. 2016;24:1003–6 Although several arthroscopic procedures for lateral ligament instability of the ankle have been reported recently, it is difficult to augment the reconstruction by arthroscopically tightening the inferior extensor retinaculum. There is also concern that when using the inferior extensor retinaculum, this is not strictly an anatomical repair since its calcaneal attachment is different to that of the calcaneofibular ligament. If a ligament repair is completed firmly, it is unnecessary to add argumentation with inferior extensor retinaculum. The authors describe a simplified technique, repair of the lateral ligament alone using a lasso-loop stitch, which avoids additionally tighten the inferior extensor retinaculum. In this paper, it is described an arthroscopic anterior talofibular ligament repair using lasso-loop stitch alone for lateral instability of the ankle that is likely safe for patients and minimal invasive. Level of evidence Therapeutic study, Level V. PubMedCrossRefPubMedCentralGoogle Scholar