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The JRGOS Case Corner is submitted by MaCalus Hogan, MD, MBA, the David Silver Professor and Chair of the University of Pittsburgh Medical Center (UPMC) Department of Orthopaedic Surgery and Chief of the UPMC Orthopaedic Surgery Service Line. Dr. Hogan is the Senior Medical Director for the Orthopaedic and Musculoskeletal Services UPMC Health Plan as well as Professor in the Department of Orthopaedic Surgery, Bioengineering, and Katz School of Business.

The research assistant, Eva Heidinger, MS, is a UPMC Research Fellow. She earned a Bachelor of Arts with Honors in Physiology and Biomedical Science from Trinity College Dublin, The University of Dublin, and a Master’s in Clinical Exercise Physiology from the University of Pittsburgh. Currently, she is completing her research fellowship with the Foot and Ankle Injury Group at UPMC.

MaCalus Hogan, MD, MBA

Case Presentation

History:

A 21-year-old female presents with persistent anterolateral right ankle pain for one year following a motor vehicle accident. Initial management included non-weight-bearing in a CAM boot, a lace-up brace, and physical therapy, resulting in partial improvement but a plateau in recovery. She remains active but experiences pain with activities like biking and running. She denies participation in formal sports but wants to remain active without discomfort. Her history includes scoliosis and appendectomy, with no tobacco, alcohol, or drug use.

Physical exam revealed tenderness over the lateral malleolus, lateral ligament complex, and anterior ankle joint. Despite full range of motion, a positive anterior drawer test indicated instability.

Diagnostic Imaging

X-ray Views:

Radiographic evaluation of the ankle demonstrates normal mineralization. There is evidence of lateral soft tissue swelling; however, no fractures are visualized. The Achilles tendon appears intact with no abnormalities noted, and there is no evidence of a heel spur. Additionally, there is no detectable ankle effusion, and the osseous alignment is within normal limits.

Preoperative MRI:

MRI findings demonstrate mild subchondral edema along the posterior talar dome and the dorsal third to half of the first tarsometatarsal joint, raising consideration for underlying chondrosis. However, no large regions of high-grade chondrosis are identified on this examination.

There is mild intrinsic signal observed along the course of the anterior talofibular, calcaneofibular, and deep deltoid ligaments, consistent with sequelae of prior injury. No evidence of acute high-grade ligamentous injury, laxity, or fiber retraction is present.

Diagnosis

The diagnosis of a high ankle sprain with lateral ligament instability and mild deltoid pain (chronic ankle instability, symptomatic) of the right lower extremity was established.

Due to minimal improvement with conservative management, surgical options, including arthroscopy, Broström procedure, and tightrope fixation, were discussed.

Treatment Plan

Arthroscopy with debridement and microfracture; Broström, lateral ligament stabilization.

Intraoperative Photos and Plan

The patient was positioned supine on the operating table, with the right lower extremity placed on a leg holder with a calf tourniquet on the right calf. General anesthesia was administered, and an ankle block was performed using a one-to-one solution of 1% lidocaine and 0.25% Marcaine for localized pain control. After placing the right lower extremity in traction, the calf tourniquet was raised to 275mmHg.

The medial portal was established using a spinal needle for localization, followed by an incision with a 15-blade. Blunt dissection was performed to access the joint, where the arthroscope was introduced. Significant synovitis was observed. A lateral portal was then created under spinal needle guidance. Using a probe, the cartilage was confirmed to be stable. Extensive synovectomy and debridement were performed. The arthroscopic portion of the procedure concluded with portal closure using 3-0 nylon sutures.

Anchors were placed at the ATFL and CFL footprints to reapproximate the lateral ligament complex to the distal fibula. The repair was reinforced by incorporating the periosteum and the inferior extensor retinaculum using a Gould modification.

For additional stability, a double-row push-lock anchor was inserted into the fibula.

Above is a lateral ligament stabilization performed on a previous patient that offers better visualization on final anchor placements.

The ankle was confirmed to be stable on anterior drawer and CFL testing. The wounds were irrigated and closed in layers using 3-0 Monocryl followed by 3-0 nylon in a running two-step fashion. A well-padded U-shaped plaster splint was applied with a sterile dressing. The foot was dressed with Betadine-soaked Adaptic and secured with Steri-Strips.

Click the Above Video to View Postoperative Examination

Postoperative Course

Postoperative X-rays:

Radiographic evaluation reveals normal bone mineralization with an intact talar dome. The ankle mortise is congruent, and the patient is status post lateral ligamentous repair and reconstruction. Mild lateral soft tissue swelling is observed, with no additional abnormalities.

The post-operative rehabilitation protocol following lateral ligament stabilization is organized into distinct phases, each defined by clinical milestones and time frames. The initial phase (weeks 0-6) emphasizes edema management and tissue protection, with the foot immobilized in a neutral position using a short leg cast. During this time, patients are non-weight-bearing and use assistive devices for moving and walking. Physical therapy targets upper body strengthening and gait training.

In Phase II (weeks 6-9), the patient transitions from a cast to a walking boot, starting a gradual weight-bearing progression according to a structured protocol. Therapy focuses on controlled joint mobilizations, proprioception, and muscle strengthening, with precautions against inversion and plantar flexion.

Phase III (weeks 10-12) sees the patient moving to full weight-bearing status, with a focus on restoring full range of motion, including inversion, while continuing strength and proprioception exercises. A semi-rigid orthotic is used to stabilize the ankle.

By Phase IV (weeks 12-16), rehabilitation progresses to advanced strengthening, proprioception, and sport-specific activities, including plyometrics and running, aimed at enhancing functional performance. Full return to sport is guided by dynamic assessments and the absence of pain or swelling. Progression throughout the protocol is adjusted based on pain levels, edema control, and functional milestones.

Implants

• Anchor Suture DX FiberTak (Knotless with #2Coreless Mach, Taper 5/BX (N) AR-8991); Quantity: 2; Implant Site: Ankle; Modifier: Right

• Anchor Suture PushLock 2.9mm x 12.5mm Arthroscopic, Biocomposite LF; Quantity: 1; Implant Site: Ankle: Modifier: Right

Hot Tips, Pearls, & Pitfalls:

Diagnosis of Chronic Ankle Instability:

• Imaging: Preoperative imaging, particularly MRI, can help to assess ligament integrity.

• Clinical Assessment is Key: Be thorough with physical examination to confirm chronic ankle instability as sometimes imaging will be unremarkable and/or lack all of the classic radiographic signs. Look for signs of ligament laxity, including the anterior drawer test and the talar tilt test, as these can inform the necessity and extent of ligament stabilization.

Treatment and Surgical Tips:

• Arthroscopic Debridement:

  • Surface Preparation: Ensure meticulous debridement of the unstable cartilage and sclerotic bone until healthy, bleeding subchondral bone is exposed to promote healing.

• Broström Procedure for Lateral Ligament Stabilization:

  • Anchor Placement: When placing anchors, ensure they are securely positioned within the fibula. Consider placing additional anchors if ligament quality is poor or if additional stability is required.

  • Avoid Over-Tightening: While stabilizing the lateral ligaments, avoid over tightening, which could restrict ankle range of motion and cause stiffness postoperatively.

  • Tissue Quality Considerations: In cases of poor ligament quality, using graft augmentation or an additional stabilization technique may enhance durability and reduce recurrence of instability.

• Pitfalls to Avoid:

  • Inadequate Preoperative Planning: Failing to assess instability severity can lead to incomplete or suboptimal treatment

  • Neglecting Proprioception Training in Post-Op: Rehabilitation should focus not only on strength but also on proprioception, as this is critical in reducing the risk of future instability

  • Understanding Recovery Timeline: Be conservative with the rehabilitation timeline for patients post-microfracture and ligament repair, as rushing the process can lead to incomplete healing and re-injury.

Submitted by MaCalus Hogan, MD, MBA