SLR - May 2021 - Joseph Cataldo

Medial and Lateral Combined Ligament Arthroscopic Repair for Multidirectional Ankle Instability 

Reference: Mansur NSB, Lemos AVKC, Baumfeld DS, et al. Medial and Lateral Combined Ligament Arthroscopic Repair for Multidirectional Ankle Instability. Foot & Ankle Orthopaedics. January 2021

Level of Evidence: Level IV, retrospective case series 

Scientific Literature Review

Reviewed By: Joseph Cataldo, DPM 
Residency Program: LIJ Forest Hills, Northwell Health – Queens, NY 

Podiatric Relevance: Chronic lateral ankle instability, if left untreated, can lead to the development of medial ankle compensation and further instability. Multidirectional ankle instability is a common occurrence seen in both podiatric and orthopedic patient populations. This condition produces anterior laxity and has been associated with a worse prognosis in both nonoperative and operative ankle sprains. This article aims to show the ongoing relevance of arthroscopy as a safe, reproducible, and faster return to activity when multidirectional instability is surgically corrected. The objective of this study is to report results of patients diagnosed with multidirectional instability treated with lateral and medial arthroscopic repair, considering both pain and function as primary outcomes. 

Methods: A retrospective study was completed between January 2018 and January 2020 with patients diagnosed with multidirectional instability who underwent ankle arthroscopy with arthroscopic tensioning medially and an arthroscopic Brostrom. Male and female patients ages 15 to 65 with complaints of ankle pain for greater than six months and clinical findings of lateral and medial instability were included in the study. Patients needed to have attempted conservative therapy for a minimum of six months to qualify for surgery. Existence of previous surgery, autoimmune diseases, neuropathy, inflammatory disease, isolated medial instability, progressive collapsing foot deformity, previous ankle infiltration, radiographic findings of ankle arthritis, cavovarus deformity, coagulopathies, a body mass index higher than 35 and surgical site infections were used as exclusion criteria. Associated injuries that coincide with ankle instability, such as osteochondral lesions, syndesmotic injury, tendon ruptures, and fractures also excluded subjects. A total of 30 ankles were included in the study after inclusion criteria were met. All patients were evaluated for pain and function according to the visual analog scale (VAS) score and the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot Score at an average of 14 months following the procedure. 

Results: AOFAS values showed a mean of 91.9 (2.9 CI) points at the last assessment with a statistically significant difference (P = .001) from baseline. VAS progression (mean 6.8, CI 0.37-0.95, CI 0.31) was also found significant (P < .001).  Complications occurred in 16% of the patients, the majority found to be minor and often self-limited. 

Conclusions: This study shows good functional results for arthroscopic lateral and medial ligament repair in patients that have been diagnosed with multidirectional ankle instability. Combined medial and lateral arthroscopic repair is a safe alternative to conservative measures and to open procedures. Although a learning curve is associated with arthroscopy, this procedure provides a safe and efficacious way to treat ankle instability. Inclusion of the deltoid ligament complex and the low invasiveness of the scope may improve the clinical outcomes for patients. This study provides the ground work for further research to be completed on this topic, such as case controls and clinical trials. 

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