Ultrasound-Guided Anterior Talofibular Ligament Repair With Augmentation Can Restore Ankle Kinematics: A Cadaveric Biomechanical Study

Soichi Hattori; Kentaro Onishi; Calvin K Chan; Satoshi Yamakawa; Yuji Yano; Philipp W Winkler; MaCalus V Hogan; Richard E Debski

doi:10.1177/23259671221111397

Ultrasound-Guided Anterior Talofibular Ligament Repair With Augmentation Can Restore Ankle Kinematics: A Cadaveric Biomechanical Study

Orthop J Sports Med. 2022 Aug 5;10(8):23259671221111397. doi: 10.1177/23259671221111397. eCollection 2022 Aug.

Authors

Soichi Hattori^{1

2

3

4}, Kentaro Onishi^{1

2}, Calvin K Chan^{1

5

6}, Satoshi Yamakawa¹, Yuji Yano¹, Philipp W Winkler^{1

6

7}, MaCalus V Hogan^{1

5

8}, Richard E Debski^{1

6}

Affiliations

¹ Orthopaedic Robotics Laboratory, Center for Biotechnology and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
² Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
³ Department of Sports Medicine, Kameda Medical Center, Kamogawa, Japan.
⁴ Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
⁵ Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
⁶ Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
⁷ Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
⁸ Foot and Ankle Injury Research (FAIR) Group, Division of Foot and Ankle Surgery, Department of Orthopedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

Abstract

Background: Anterior talofibular ligament (ATFL) repair of the ankle is a common surgical procedure. Ultrasound (US)-guided anchor placement for ATFL repair can be performed anatomically and accurately. However, to our knowledge, no study has investigated ankle kinematics after US-guided ATFL repair.

Hypothesis: US-guided ATFL repair with and without inferior extensor retinaculum (IER) augmentation will restore ankle kinematics.

Study design: Controlled laboratory study; Level of evidence, 4.

Methods: A 6 degrees of freedom robotic testing system was used to apply multidirectional loads to fresh-frozen cadaveric ankles (N = 9). The following ankle states were evaluated: ATFL intact, ATFL deficient, combined ATFL repair and IER augmentation, and isolated US-guided ATFL repair. Three loading conditions (internal-external rotation torque, anterior-posterior load, and inversion-eversion torque) were applied at 4 ankle positions: 30° of plantarflexion, 15° of plantarflexion, 0° of plantarflexion, and 15° of dorsiflexion. The resulting kinematics were recorded and compared using a 1-way repeated-measures analysis of variance with the Benjamini-Hochberg test.

Results: Anterior translation in response to an internal rotation torque significantly increased in the ATFL-deficient state compared with the ATFL-intact state at 30° and 15° of plantarflexion (P = .022 and .03, respectively). After the combined US-guided ATFL repair and augmentation, anterior translation was reduced significantly compared with the ATFL-deficient state at 30° and 15° of plantarflexion (P = .0012 and .005, respectively). Anterior translation was not significantly different for the isolated ATFL-repair state compared with the ATFL-deficient or ATFL-intact states at 30° and 15° of plantarflexion.

Conclusion: Combined US-guided ATFL repair with augmentation of the IER reduced lateral ankle laxity due to ATFL deficiency. Isolated US-guided ATFL repair did not reduce laxity due to ATFL deficiency, nor did it increase instability compared with the intact ankle.

Clinical relevance: US-guided ATFL repair with IER augmentation is a minimally-invasive technique to reduce lateral ankle laxity due to ATFL deficiency. Isolated US-guided ATFL repair may be a viable option if accompanied by a period of immobilization.

Keywords: anterior talofibular ligament repair; augmentation; chronic ankle instability; kinematics; ultrasound-guided surgery.