MaCalus Hogan, MD, and Orthopaedic Robotics Laboratory Team Study Ultrasound-Guided Anterior Talofibular Ligament Repair with Augmentation

MaCalus V. Hogan, MD, MBA, professor, UPMC Department of Orthopaedic Surgery – along with several other faculty members and researchers from the University of Pittsburgh Orthopaedic Robotics Laboratory – published “Ultrasound-Guided Anterior Talofibular Ligament Repair with Augmentation Can Restore Ankle Kinematics: A Cadaveric Biomechanical Study” in the Orthopaedic Journal of Sports Medicine in August 2022.

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, the research team was not aware of any study which investigated ankle kinematics after ultrasound-guided ATFL repair.

Their study aimed to prove that US-guided ATFL repair with and without inferior extensor retinaculum (IER) augmentation will restore ankle kinematics. They used a 6 degrees of freedom robotic testing system 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.

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.

The team concluded that 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.

US-guided ATFL repair with IER augmentation is a minimally-invasive technique to reduce lateral ankle laxity due to ATFL deficiency. The study shows that isolated US-guided ATFL repair may be a viable option if accompanied by a period of immobilization.

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