Medial and Lateral Combined Ligament Arthroscopic Repair for Multidirectional Ankle Instability: Case Series

Abstract Introduction: The high prevalence of sprains in the population has provided a substantial number of patients with lateral instability of the ankle. The continuity of this condition can lead to the progressive loosening of the medial containment structures, generating a multidirectional rotational instability. The deltoid approach through the imbrication of its components has been proposed as a solution for these patients. The arthroscopic technique has been described as an alternative.

Methods: This is a retrospective study with patients diagnosed with multidirectional instability and submitted to an ankle arthroscopy with medial repair (arthroscopic tensioning) and lateral (arthroscopic Brostrom) between January 2018 and January 2020. All patients will fill an epidemiological questionnaire and will be evaluated for pain and function according to the Visual Analogue Scale (VAS) and the American Orthopaedic Foot and Ankle Society Score (AOFAS) at 12 months (6-24 months) average of follow-up.

Discussion: The combined medial and lateral arthroscopic repair may be an effective and safe alternative in the treatment of multidirectional instability. The inclusion of the deltoid complex and the low invasiveness of this technique can improve the clinical outcomes of these patients. Additional studies, with a prospective and comparative methodology are required to sustain this proposal.

Design: Level IV. Retrospective case series.

Keywords: ankle injuries; lateral ligament; collateral ligaments; joint instability

Study Overview

• Status: Completed
• Conditions: Ankle Injuries; Joint Instability; Ligament Injury; Deltoid Ligament; Sprain (Strain) (Ankle); Talofibular Ligament Tear
• Intervention / Treatment: Procedure: Arthroscopic Brostrom combined with Arthroscopic Deltoid Repair

• Study Type: Observational
• Enrollment (Actual): 29

Contacts and Locations

Study Locations

• Brazil
  • SP
    • Sao Paulo, SP, Brazil, 04022-001
      • Federal University of São Paulo

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 15 years to 65 years (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Tertiary teaching hospital patients, athletes and non-athletes.

Description

Inclusion Criteria:

• complaints about ankle loosening for the last six months
• clinical findings of lateral and medial instability

Exclusion Criteria:

• existence of previous surgery
• autoimmune diseases
• neuropathy
• inflammatory disease
• isolated medial instability
• flatfoot
• previous ankle infiltration
• radiographic findings of ankle arthritis
• cavovarus deformity
• coagulopathies
• body mass index over 35
• associated injuries, such as osteochondral lesions
• syndesmosis instability
• tendon ruptures
• fractures

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort

Intervention / Treatment

Multidirectional; Arthroscopic lateral ligament repair combined with deltoid arthroscopic ligament repair.

Procedure: Arthroscopic Brostrom combined with Arthroscopic Deltoid Repair; After anesthesia and surgical site preparation, traditional arthroscopic portals were performed. A 4.5mm set was used to clean the joint and assess possible associated injuries. Anterolateral and anteromedial impacts were resected when needed. Lateral and medial instability were confirmed arthroscopically, and ligament repairs prepared, starting by the lateral compartment. A traditional Arthroscopic Brostrom was performed, using one anchor and suture passers. Sutures are passed but not tightened. Medial anchor insertion is executed at the medial malleolus, in the quadrant described by Vega et al. Sutures were passed respecting the safe zone illustrated by Acevedo at al. The ankle was positioned in neutral (no posterior drawer) and the lateral sutures tightened with arthroscopic knots. Finally, the medial repair is finalized by tightening the deltoid sutures with the ankle at the same position. Portals were closed and a dressing applied.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
American Orthopedic Foot and Ankle Society - Hindfoot Score (AOFAS)	Functional Score (0 to 100 | 100 best score possible | 0 worst score possible)	6th post-operataive month

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Visual Analogue Scale (VAS)	Pain Score (0 to 10 | 10 worst score possible | 0 best score possible)	6th post-operataive month
Complications	Surgical complications	6th post-operataive month

Collaborators and Investigators

• Sponsor: Federal University of São Paulo
• Investigators: Principal Investigator: Nacime Salomão Barbachan Mansur, MD, PhD, Federal University of São Paulo

Study record dates

Study Major Dates

• Study Start (Actual): July 1, 2019
• Primary Completion (Actual): September 1, 2020
• Study Completion (Actual): January 1, 2021

Study Registration Dates

• First Submitted: July 2, 2020
• First Submitted That Met QC Criteria: July 2, 2020
• First Posted (Actual): July 7, 2020

Study Record Updates

• Last Update Posted (Actual): February 4, 2021
• Last Update Submitted That Met QC Criteria: February 2, 2021
• Last Verified: February 1, 2021

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Leg Injuries; Joint Diseases; Musculoskeletal Diseases; Wounds and Injuries; Sprains and Strains; Ankle Injuries; Joint Instability
• Other Study ID Numbers: Multi_EPM

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: According to the ICMJE data sharing police, core records will be shared at an online depository and available upon request.
• IPD Sharing Time Frame: After the article is published.
• IPD Sharing Access Criteria: A formal requisition will be needed, directly addressed to the main researcher. A good scientific reason must be included.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF; ANALYTIC_CODE; CSR

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No