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Ultrasound-Guided Ankle Lateral Ligament Stabilization

  • Management of Ankle Instability (M Hogan, Section Editor)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

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.

Recent Findings

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.

Summary

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.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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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.

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  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.

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  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.

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Authors and Affiliations

  1. Department of Sports Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba Prefecture, 2968602, Japan

    Soichi Hattori & Carlo Antonio D. Alvarez

  2. Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan

    Soichi Hattori

  3. Department of Orthopedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA

    Stephen Canton, Macalus V. Hogan & Kentaro Onishi

  4. Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA

    Kentaro Onishi

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Correspondence to Soichi Hattori.

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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.

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Hattori, S., Alvarez, C.A.D., Canton, S. et al. Ultrasound-Guided Ankle Lateral Ligament Stabilization. Curr Rev Musculoskelet Med 12, 497–508 (2019). https://doi.org/10.1007/s12178-019-09592-0

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