Outcome of a Modified Broström-Gould Procedure for Lateral Ankle Instability

Introduction: Ankle sprains affect 200'000 persons/year in Switzerland. Most incidences are successfully treated by conservative measures but 20% require reconstruction for symptomatic chronic lateral ankle instability. This study evaluates the functional outcome after a modified Broström-Gould technique as measured by different clinical scores and compares the functional outcome of this technique with other surgical treatments of ankle instability. Methods: This retrospective cohort study evaluates 47 patients who underwent a modified Broström-Gould procedure using suture anchors to refix the lateral ankle capsuloligamentary structures at our institution from 2005 to 2009 with a minimum follow-up of one year (13-72 Mo). All patients were operated by one single surgeon and evaluated by an independent examiner. The function was assessed using 4 scores including: the AOFAS (American Orthopaedic Foot and Ankle Society's Score) hindfoot score; the FAAM (Foot and Ankle Ability Measurement); the CAIT (Cumberland Ankle Instability Tool); the CAIS (Chronic Ankle Instability Scale). Results: Six patients were excluded leaving 41 patients for examination. 34 patients (83%) thought that their ankle was more stable after the surgery, 7 (17%) did not feel any difference. 27 patients were very satisfied, 11 satisfied and 3 not satisfied. Reasons for non satisfaction included persistent instability and pain. Ankle mobility returned to normal in 93% of patients. Five patients had transcient hypoesthesy in the area of the superficial peroneal nerve. One patient suffered from a superficial infection treated successfully by local measures. 80% had the perception of a normal ankle, 20% thought to be below normal. At follow-up the AOFAS was 89/100 (37-100), the FAAM 85/100% (35-100%), the CAIT 20/30 (5-30), and the CAIS 74/100% (27-100%). Conclusions: The modified Broström-Gould procedure, which belongs to the anatomic ankle stabilizations is relatively simple and offers good outcome that satisfied 93% of the patients in the present study. No active stabilisator is sacrificed. Preservation of the ankle mobility is better and the complication rate is lower than after non-anatomical procedures described in the literature. The CAIT appeared as the most severe score compared to the other scales used in our study.

Evaluation of a modified Broström-Gould procedure for treatment of chronic lateral ankle instability: A retrospective study with critical analysis of outcome scoring.

BACKGROUND: Chronic lateral ankle instability accounts for 20% of the ankle injuries. This study evaluates functional outcome of the modified Broström-Gould technique using suture anchors, with 4 different clinical scores. METHODS: A consecutive series of 41 patients were included with a minimum follow-up of one year. The function was assessed using 4 clinical scores including: the AOFAS for hind foot; the FAAM; the CAIT and the CAIS. RESULTS: Out of 41 patients; 27 patients were very satisfied, 11 satisfied and 3 were not satisfied. Ankle mobility returned to normal in 93% of patients. At follow-up the AOFAS was 89/100 (37-100), the FAAM 85/100% (35-100%), the CAIT 20/30 (5-30), and the CAIS 74/100% (27-100%). CONCLUSION: Outcome of modified Broström-Gould procedure is good with high satisfaction rate in terms of ankle mobility. The disparity in outcome of scores, signals towards the need of a standard evaluation system.

Critical evaluation of outcome scales assessment of lateral ankle ligament reconstruction

Introduction: Les résultats d'une chirurgie du pied et de la cheville peuvent être évalués par des scores spécifiques à la région anatomique ainsi que par des scores spécifiques à la pathologie. Beaucoup de scores existent rendant la comparaison entre les études difficile. La présente étude se focalise sur une pathologie fréquente du pied et de la cheville et compare les résultats obtenu par deux scores spécifiques à la région et deux scores spécifiques à la pathologie. Méthode: Nous avons revu 41 patients ayant bénéficié d'une plastie ligamentaire externe de la cheville. Quatre scores ont été administrés simultanément: the Cumberland Ankle Instability Tool (CAIT) et the Chronic Ankle Instability Scale (CAIS), spécifiques à la pathologie, the American Orthopedic Foot & Ankle Society (AOFAS) hindfoot scale et the Foot and Ankle Ability Measure comprenant deux parties (FAAM1 et FAAM2), spécifiques à la région anatomique. Le degré de corrélation entre les scores a été évalué par le coefficient de corrélation de Pearson. L'analyse graphique des variances a été utilisée pour le choix de tests paramétriques versus non paramétriques. Des tests non paramétriques, le Kruskal-Wallis pour éliminer l'hypothèse nulle et le Mann-Whitney pour la comparaison entre les scores deux à deux, ont été utilisés. Résultats: Une différence significative (p<.005) a été démontrée entre le CAIS et l'AOFAS (p=.0002), entre le CAIS et le FAAM1 (p=.0001) et entre le CAIT et l'AOFAS (p=.0003) Conclusions: Cette étude compare les performances de quatre scores dont deux spécifiques à la région anatomique et deux spécifiques à la pathologie. Nous avons démontré une bonne corrélation entre les scores ainsi que des différences significatives entre les résultats obtenus par chacun d'eux. Les résultats obtenus par les scores spécifiques à la pathologie semblent être plus précis que ceux obtenus par les scores spécifiques à la région anatomique. De plus, nous avons mis en évidence une forte corrélation entre l'AOFAS et les autres scores. Le FAAM semble être un bon compromis car il offre la possibilité, du fait de ses deux parties, d'évaluer le résultat en fonction de la demande fonctionnelle du patient. Perspectives: Un algorithme est proposé qui permet d'évaluer la littérature spécifique de manière plus critique et peut s'adapter également à la recherche et à la clinique relative à d'autres pathologies du pied et de la cheville

Critical evaluation of outcome scales assessment of lateral ankle ligament reconstruction.

BACKGROUND: Outcome following foot and ankle surgery can be assessed by disease- and region-specific scores. Many scoring systems exist, making comparison among studies difficult. The present study focused on outcome measures for a common foot and ankle abnormality and compared the results obtained by 2 disease-specific and 2 body region-specific scores. METHODS: We reviewed 41 patients who underwent lateral ankle ligament reconstruction. Four outcome scales were administered simultaneously: the Cumberland Ankle Instability Tool (CAIT) and the Chronic Ankle Instability Scale (CAIS), which are disease specific, and the American Orthopedic Foot & Ankle Society (AOFAS) hindfoot scale and the Foot and Ankle Ability Measure (FAAM), which are both body region-specific. The degree of correlation between scores was assessed by Pearson's correlation coefficient. Nonparametric tests, the Kruskal-Wallis and the Mann-Whitney test for pairwise comparison of the scores, were performed. RESULTS: A significant difference (P < .005) was observed between the CAIS and the AOFAS score (P = .0002), between the CAIS and the FAAM 1 (P = .0001), and between the CAIT and the AOFAS score (P = .0003). CONCLUSIONS: This study compared the performances of 4 disease- and body region-specific scoring systems. We demonstrated a correlation between the 4 administered scoring systems and notable differences between the results given by each of them. Disease-specific scores appeared more accurate than body region-specific scores. A strong correlation between the AOFAS score and the other scales was observed. The FAAM seemed a good compromise because it offered the possibility to evaluate the patient according to his or her own functional demand. CLINICAL RELEVANCE: The present study contributes to the development of more critical and accurate outcome assesment methods in foot and ankle surgery.

Proprioception in ankle sprain from exercises and bandages

Ankle sprains are the most common injuries in sports, usually causing damage to the lateral ligaments. Recurrence has as usual result permanent instability, and thus loss of proprioception. This fact, together with residual symptoms, is what is known as chronic ankle instability, CAI, or FAI, if it is functional. This problem tries to be solved by improving musculoskeletal stability and proprioception by the application of bandages and performing exercises. The aim of this study has been to review articles (meta-analisis, systematic reviews and revisions) published in 2009-2015 in PubMed, Medline, ENFISPO and BUCea, using keywords such as “sprain instability”, “sprain proprioception”, “chronic ankle instability”. Evidence affirms that there does exist decreased proprioception in patients who suffer from CAI. Rehabilitation exercise regimen is indicated as a treatment because it generates a subjective improvement reported by the patient, and the application of bandages works like a sprain prevention method limiting the range of motion, reducing joint instability and increasing confidence during exercise. As podiatrists we should recommend proprioception exercises to all athletes in a preventive way, and those with CAI or FAI, as a rehabilitation programme, together with the application of bandages. However, further studies should be generated focusing on ways of improving proprioception, and on the exercise patterns that provide the maximum benefit.

Traumatic rupture of both peroneal longus and brevis tendons.

Injuries of peroneal tendons are rare. Diagnosis of traumatic rupture is often late and presents as chronic ankle instability. A case of a complete traumatic rupture of both peroneal longus and brevis tendons with acute clinical and radiological diagnosis is presented. Surgical repair was performed by direct end-to-end suture on the 4th day after trauma, with excellent functional outcome at 1-year follow-up.

A influência da fadiga nos músculos eversores durante a entorse lateral do tornozelo

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Instrumentos de avaliação para limitações funcionais associadas à instabilidade crônica de tornozelo: uma revisão sistemática da literatura

A instabilidade de tornozelo é definida como a sua tendência para sofrer falseios e entorses de repetição após a ocorrência de entorse lateral. Como a presença de instabilidade é definida por meio das queixas relatadas pelo indivíduo, apresenta caráter subjetivo, sendo importante identificar o melhor instrumento de avaliação para a determinação de sua presença e/ou gravidade. O objetivo deste estudo foi revisar, de forma sistemática, instrumentos de avaliação concebidos para pacientes com instabilidade crônica de tornozelo. Foram realizadas pesquisas bibliográficas nas bases de dados PubMed, Embase, BVS, LILACS e SciELO para identificar os instrumentos elegíveis. No total, seis estudos foram incluídos e apresentaram cinco instrumentos diferentes - Foot and Ankle Disability Index (FADI), Ankle Joint Functional Assessment Tool (AJFAT), Foot and Ankle Ability Measure (FAAM), Ankle Joint Functional Assessment Tool (AII) e Cumberland Ankle Instability Tool (CAIT). Foram encontrados instrumentos com qualidade que detectam limitações funcionais em indivíduos com instabilidade crônica de tornozelo, não sendo instrumentos válidos para diagnóstico de instabilidade. O CAIT mostrou-se a ferramenta mais completa, mas não foi validada em uma população específica de indivíduos com condição de instabilidade do tornozelo. Observa-se a necessidade de mais estudos clinimétricamente válidos a fim de atestar a sua validade para se obter uma ferramenta eficaz e completa da instabilidade funcional do tornozelo.

Instabilidade crónica da tíbio-társica

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Efeito da ligadura de reposicionamento do perónio em basquetebolistas adultos com instabilidade crónica da tibiotársica

Introdução: A instabilidade crónica da tibiotársica apresenta uma elevada incidência e prevalência nos basquetebolistas, pelo que é fundamental aprofundar as estratégias existentes para a redução das limitações funcionais e mecânicas decorrentes desta condição. Objetivo: comparar o efeito da ligadura de reposicionamento do perónio segundo Mulligan com o de uma ligadura placebo imediatamente após a sua aplicação e após o teste de corrida (Yo-Yo IRT). Metodologia: Estudo cruzado de amostras emparelhadas. Participantes: 16 basquetebolistas adultos (10 homens, 6 mulheres) com instabilidade crónica da tibiotársica com idade média de 21,50 ± 2,76 anos. Procedimentos de avaliação e intervenção: Avaliação do controlo postural estático (teste de apoio unipodal com os olhos fechados numa plataforma de forças durante 15 segundos), performance funcional (hop test em 8 e hop test lateral) e controlo neuromuscular (tempo de latência do músculo longo peronial durante o movimento de inversão repentina) em duas sessões: Mulligan e Placebo. Resultados: Em ambos Hop tests não houve um efeito significativo para o fator ligadura (p>0,17) mas houve para o fator tempo (p<0,03). No tempo de latência do músculo longo peronial, houve um efeito significativo para o fator tempo (p=0,042) e interação significativa entre os dois fatores (p=0,028). Em relação ao controlo postural, nas variáveis de deslocamento do CoP em x e y, área de deslocamento do CoP, velocidade de deslocamento do CoP, e comprimento total do CoP não houve nenhum efeito significativo (p≥0,10). Conclusão: Não há diferenças no controlo postural estático nem na performance funcional de basquetebolistas com instabilidade crónica da tibiotársica entre a ligadura de reposicionamento do perónio de Mulligan e uma ligadura placebo. Contudo, a ligadura de Mulligan parece reduzir o tempo de latência do longo peronial após a corrida quando comparada com uma ligadura placebo.

Revisione sistematica della letteratura sull'efficacia del training propriocettivo nell'instabilità cronica di caviglia

Introduzione: In seguito ad una distorsione di caviglia, circa il 40% dei soggetti tende a sviluppare sintomi ricorrenti e persistenti, come dolore, gonfiore, alterazione della percezione o recidive, che a lungo termine potrebbero portare ad una instabilità cronica di caviglia. Questa problematica potrebbe limitare i soggetti nelle varie attività della vita quotidiana e nelle attività sportive, riducendo la loro qualità della vita. Solitamente, il trattamento in seguito ad una distorsione o in soggetti affetti da instabilità cronica di caviglia è il training propriocettivo. Obiettivi: Confrontare gli studi raccolti e i risultati ottenuti da essi e valutare se il training propriocettivo potrebbe essere efficace o meno nei soggetti che presentano l’instabilità cronica di caviglia. Metodi di ricerca: Le ricerche per questa revisione sistematica sono state fatte sulle banche dati “PubMed”, “PEDro” e “Cochrane Library”. Le parole chiave utilizzate sono “ankle sprains”, “chronic ankle instability”, “ankle injuries”, “proprioceptive training”, “proprioception”, “pain”, “disability” e “quality of life”. Sono stati inclusi soltanto RCTs inerenti al quesito di ricerca (PICOS) e conformi ai criteri di eleggibilità. Risultati: In questa revisione sistematica sono stati inclusi 4 RCTs, che mettono a confronto il training propriocettivo con altre metodiche riabilitative. Si sono osservati miglioramenti per quanto riguarda la disabilità, la qualità di vita, l’equilibrio dinamico, l’equilibrio statico e gli outcome riportati dai partecipanti. Conclusioni: Il training propriocettivo risulta essere efficace nel migliorare la sintomatologia data dall’instabilità cronica di caviglia e anche la stabilità e propriocezione dell’articolazione. Si dovrebbero eseguire ulteriori studi per approfondire l'efficacia di questo trattamento sul dolore e anche la sua efficacia a lungo termine.

Disambiguating the Effects of Social Instability Stress in Adolescence on Learning and Memory Tasks that Involve the Medial Prefrontal Cortex and Hippocampus

Exposure to chronic stress can alter the structure and function of brain regions involved in learning and memory, and these effects are typically long-lasting if the stress occurs during sensitive periods of development. Until recently, adolescence has received relatively little attention as a sensitive period of development, despite marked changes in behaviour, heightened reactivity to stressors, and cognitive and neural maturation. Therefore, the purpose of the present study was to investigate the long-term effects of chronic stress in adolescence on two spatial learning and memory tasks (Morris water maze and Spatial Object Location test) and on a working memory task (Delayed Alternation task). Male rats were randomly assigned to chronic social instability stress (SS; daily 1 hour isolation and subsequent change of cage partner between postnatal days 30 and 45) or to a no-stress control group (CTL). During acquisition learning in the Morris water maze task, SS rats demonstrated impaired long-term memory for the location of the hidden escape platform compared to CTL rats, although the impairment was only seen after the first day of training. Similarly, SS rats had impaired long-term memory in the Spatial Object Location test after a long delay (240 minutes), but not after shorter delays (15 or 60 minutes) compared to CTL rats. On the Delayed Alternation task, which assessed working memory across delays ranging from 5 to 90 seconds, no group differences were observed. These results are partially in line with previous research that revealed adult impairment on spatial learning and memory tasks after exposure to chronic social instability stress in adolescence. The observed deficits, however, appear to be limited to long-term memory as no group differences were observed during brief periods of retention.

ANTERIOR SHOULDER INSTABILITY: CORRELATION BETWEEN MAGNETIC RESONANCE ARTHROGRAPHY, ULTRASOUND ARTHROGRAPHY AND INTRAOPERATIVE FINDINGS

The purpose of the present study was to determine ultrasound (US) arthrography diagnostic accuracy in patients with recurrent shoulder dislocation by comparing US arthrography and magnetic resonance arthrography (MRA) with intraoperative findings. Fifty-six consecutive patients with diagnosis of chronic anterior instability of the shoulder were evaluated for assessment of bone and soft tissue lesions by three radiologists. Twenty-five cases were confirmed by surgery. Sensitivity, specificity, inter-and intraobserver agreement were calculated. Ultrasound sensitivity ranged from 20% to 100% and specificity from 25% to 90%. MRA sensitivity ranged from 80% to 100% and specificity from 50% to 100%. Interobserver agreement was good for MRA (0.54-0.70) and fair for US arthrography (0.19-0.40). Despite a higher interobserver variability for US arthrography than for MRA, our results indicate that US is capable of demonstrating bone and soft tissue lesions related to chronic instability of the shoulder in the presence of intra-articular fluid. (E-mail: marcelo_simao@hotmail.com) (C) 2012 World Federation for Ultrasound in Medicine & Biology.

Scores de mesure fonctionnelle articulaire pour le praticien [Joint functional outcome score for the clinician].

The sports clinician faces multiple treatment options when dealing with overload injuries, and it is important to evaluate their outcomes. Multiple scores exist, some clincian rated (CRO), others patient rated (PRO), the latter being currently favoured. This review presents some of these scores and we selected the ones we feel are the most appropriate for a sports clinician. We considered these common problems: tennis elbow, rotator cuff issues, groin pain, patellofemoral pain syndrome, achilles tendinopathy and ankle instability. In addition, an activity level score is useful to weigh the result in the context of return to performance. These scores help to create a common language between therapists and to evaluate treatments objectively.