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

September 2, 2022

Kentaro Onishi, DO, assistant professor, UPMC Department of Physical Medicine and Rehabilitation, and 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.

View full study and contributors.