Anatomical study of the inferior extensor retinaculum and the oblique superolateral band: implications for the Brostrom-Gould procedure

Purpose The Brostrom-Gould procedure is currently the gold standard surgical choice for the treatment of chronic ankle instability; it can significantly improve ankle function and stability in patients. However, recent studies have reported doubts regarding the feasibility of the inferior extensor retinaculum (IER) after Brostrom-Gould and therapeutic effects compared with the Brostrom procedure. The purpose of the present study was to observe the anatomical characteristics of the lateral part of the IER using cadaveric bodies in order to guide the surgical operation of chronic ankle instability. Methods Twenty-three cadaveric ankles were dissected. The morphology of the IER and its internal structure was observed and recorded for each ankle. The shortest distance between the Stem ligament of the IER and the anterior fibular periosteum (AFP) was measured and recorded, then attempts were made to suture the Stem to the AFP. Results Twelve of the cadaveric ankles were observed as having an oblique superolateral band (OSLB) that had a tough texture upward of the lateral IER connecting with SL, as are the characteristics of the oblique superolateral band (OSLB) reported in previous studies. The inner and outer membrane of the OSLB were connected with inner and outer membrane of Stem. The average value of the distance between the Stem and AFP was 11.60 ± 2.71 mm, and the maximum and the minimum distance were 19.04 mm and 6.53 mm, respectively. The P -value (P = 0.2) resulting from a single sample K-S test confirmed that the distribution of distances conformed to normality. None of the SL in the study could be sutured to the AFP. Conclusion The OSLB of the IER has a tough texture and connects with the Stem, and has the potential be utilised in the Brostrom-Gould procedure. However, we do not recommend utilization of the Stem in this operation regardless of the distance between the AFP and the Stem. When the Stem cannot be used to enhance repair in this operation, other solutions can be used for strengthening and to protect the repaired ATFL.

Do We Need Extensor Retinacular Enhancement on Broström Lateral Ankle Repair? A Systematic Review and Meta-analysis

Aims This meta-analysis compared inferior extensor retinaculum (IER) enhancement in Broström-Gould procedure and anatomical Broström repair. We aim to evaluate functional ankle score (American Orthopaedic Foot & Ankle Society (AOFAS) score, Karlsson score), talar tilt, talar anterior translation, and complications between both groups. Methods A comprehensive systematic literature search was carried out using Wiley Library, Scopus, Pubmed, ScienceDirect, and EuropePMC databases from inception up until 19 December 2020. While the intervention was IER enhancement, the control was those without IER enhancement. The primary outcome was the functional ankle score (AOFAS and Karlsson score). The secondary outcomes were talar tilt, talar anterior translation, and other complications. Results There was a total of 298 patients from 7 studies included in this systematic review and meta-analysis. IER enhancement was associated with lower AOFAS (mean difference -1.115 [-2.197, -0.033], p=0.043; I2: 0%) during follow-up. Lower Karlsson score was observed in the IER enhancement group (mean difference -2.004 [-3.442, -0.567], p=0.006; I2: 3.71%) during follow-up. Talar tilt (mean difference -0.145 degree [-0.436, 0.146], p=0.329; I2: 0%) and anterior displacement (mean difference -0.109 mm [-0.096, 0.314], p=0.299; I2: 0%) in the two groups were similar on follow-up. The complications were similar in both groups (OR 0.87 [0.40, 1.89], p=0.719; I2: 0%). Meta-regression analysis indicates that the association between IER and AOFAS was not affected by age (p=0.927) and male gender (p=0.930). Conclusion This meta-analysis showed that ATFL repair with non-IER enhancement was non-inferior compared to those with IER enhancement.

Anatomical Study of the Inferior Extensor Retinaculum and the Oblique Superolateral Band: Implications for the Brostrom-Gould Procedure

Purpose The Brostrom-Gould procedure is currently the gold standard surgical choice for the treatment of chronic ankle instability; it can significantly improve ankle function and stability in patients. However, recent studies have reported doubts regarding the feasibility of the inferior extensor retinaculum (IER) after Brostrom-Gould and therapeutic effects compared with the Brostrom procedure. The purpose of the present study was to observe the anatomical characteristics of the lateral part of the IER using cadaveric bodies in order to guide the surgical operation of chronic ankle instability.Methods Twenty-three cadaveric ankles were dissected. The morphology of the IER and its internal structure was observed and recorded for each ankle. The shortest distance between the Stem ligament of the IER and the anterior fibular periosteum (AFP) was measured and recorded, then attempts were made to suture the Stem to the AFP.Results Twelve of the cadaveric ankles were observed as having an oblique superolateral band (OSLB) that had a tough texture upward of the lateral IER connecting with SL, as are the characteristics of the oblique superolateral band (OSLB) reported in previous studies. The inner and outer membrane of the OSLB were connected with inner and outer membrane of Stem. The average value of the distance between the Stem and AFP was 11.60±2.71mm, and the maximum and the minimum distance were 19.04mm and 6.53mm, respectively. The P -value (P=0.2) resulting from a single sample K-S test confirmed that the distribution of distances conformed to normality. None of the SL in the study could be sutured to the AFP. Conclusion The OSLB of the IER has a tough texture and connects with the Stem, and has the potential be utilised in the Brostrom-Gould procedure. However, we do not recommend utilization of the Stem in this operation regardless of the distance between the AFP and the Stem. When the Stem cannot be used to enhance repair in this operation, other solutions can be used for strengthening and to protect the repaired ATFL.

Additional Inferior Extensor Retinaculum Augmentation After All-Inside Arthroscopic Anterior Talofibular Ligament Repair for Chronic Ankle Instability Is Not Necessary

Background: Although several arthroscopic surgical techniques for the treatment of chronic ankle instability (CAI) have been introduced recently, the effect of inferior extensor retinaculum (IER) augmentation remains unclear. Purpose: To compare the clinical outcomes after arthroscopic anterior talofibular ligament (ATFL) repair according to whether additional IER augmentation was performed or not. Study Design: Cohort study; Level of evidence, 3. Methods: We performed a retrospective review of consecutive patients who underwent arthroscopic ATFL repair surgery for CAI between 2016 and 2018. The mean age of the patients was 35.2 years (range, 19-51 years), and the mean follow-up period was 32.6 months (range, 24-48 months). Patients were divided into 2 groups according to the surgical technique used for CAI: arthroscopic ATFL repair (group A; n = 37) and arthroscopic ATFL repair with additional IER augmentation (group R; n = 45). The pain visual analog scale, American Orthopaedic Foot & Ankle Society score, Foot and Ankle Outcome Score, and the Karlsson Ankle Function Score were measured as subjective outcomes, and posturographic analysis was performed using a Tetrax device as an objective outcome. Radiologic outcome evaluations were performed preoperatively and at 2 years postoperatively using stress radiographs and axial view magnetic resonance imaging (MRI). Results: Out of 101 patients, 19 (18.5%) were excluded per the exclusion criteria, and 82 were evaluated. We identified 6 retears (7.3%) based on postoperative MRI evaluation. All patients who had ATFL retear on MRI (8.1% [3/37] in group A and 6.7% [3/45] in group R) demonstrated recurrent CAI with functional discomfort and anterior displacement >3 mm as compared with the intact contralateral ankle. All clinical scores and posturography results were improved after surgery in both groups ( P < .001). However, there were no significant differences in the clinical results and radiologic findings between the groups. Conclusion: The clinical and radiologic outcomes of patients with CAI improved after all-inside arthroscopic ATFL repair. However, additional IER augmentation after arthroscopic ATFL repair did not guarantee better clinical outcomes.

Anatomical variations and interconnections of the superior peroneal retinaculum to adjacent lateral ankle structures: a preliminary imaging anatomy study

Aim: This imaging anatomy study aimed at detecting anatomical variations and potential interconnections of the superior peroneal retinaculum to other lateral stabilizing structures. Materials and methods: We retrospectively reviewed the imaging archives of 63 patients (38 females, 25 males, mean age 32.7, range 18–58 years) with available ankle US, MR and CT images to detect whether US and MR can detect the presence of interconnections between the superior peroneal retinaculum and the anterior talofibular ligament, inferior extensor retinaculum and peroneal tendon sheath. We evaluated the presence of common anatomical variations including low peroneus brevis muscle belly, peroneal tubercle, os peroneum, and retromalleolar fibular groove shape in relation to the presence of superior peroneal retinaculum connections. Results: The connections of the superior peroneal retinaculum can be revealed on magnetic resonance imaging (MRI) and ultrasound (US). The connection to the anterior talofibular ligament was located (a) inferior to the lateral malleolus, (b) at the level of the lateral malleolus and (c) on both levels, respectively (a) 49.2% on MRI and 39.7% on US, p <0.05, (b) 44.4% and 58.7%, p <0.05, 36.5% and (c) 27%, p <0.05. Superior peroneal retinaculum–inferior extensor retinaculum (MRI 47.6%, US 28.6% p <0.001) and superior peroneal retinaculum–peroneal tendon sheath (MRI 22.2%, US 25.4% p >0.05) connections were also found both on MR and US. Conclusion: Ankle US and MR revealed interconnections between the superior peroneal retinaculum and the anterior talofibular ligament, inferior extensor retinaculum, and superior peroneal retinaculum. Our results are a starting point for further studies on the connections of the superior peroneal retinaculum and the applicability of ultrasound and MRI in assessing their occurrence. Knowledge of the anatomical connections of the superior peroneal retinaculum may help radiologists with the assessment of lateral ankle injuries, and surgeons with treatment planning.

The Flexor Retinaculum Connects the Surrounding Structures into the Medial Ankle Complex

This study aimed to prove the hypothesis that the medial structures of the ankle are interconnected through the flexor retinaculum’s projections. We conducted a retrospective re-evaluation of 132 MRI examinations of the ankle joint from 57 females and 75 males with an age range of 18–65 and a mean age of 35 years. The correlation between the presence of connections between the flexor retinaculum and the deltoid ligament, the spring ligament, the inferior extensor retinaculum, the paratenon, the fibulotalocalcaneal ligament, the fascia covering the abductor hallucis, and the flexor fibrous sheath were studied. The most common connections of the flexor retinaculum were to the deltoid ligament (97%), the fibulotalocalcaneal ligament (84.1%), and the flexor fibrous sheath (83.3%). Interconnection between the flexor retinaculum and the deltoid ligament correlated with the presence of connections between the flexor retinaculum and the inferior extensor retinaculum, the paratenon, and the spring ligament. Side difference was noticed in connections to the flexor fibrous sheath, the deltoid ligament, the fascia on the abductor hallucis, and the paratenon (p < 0.05). The flexor retinaculum formed a more complex anatomical unit with adjacent structures.

Comparison of Clinical Outcomes after Arthroscopic Anterior Talofibular Ligament Repair with or without Inferior Extensor Retinaculum Augmentation

Category: Sports; Arthroscopy Introduction/Purpose: Though several arthroscopic surgical techniques for the treatment of lateral instability of the ankle have been introduced recently; the effect for the inferior extensor retinaculum augmentation is remained unclear. The purpose of this study was to compare the clinical outcomes after arthroscopic anterior talofibular ligament (ATFL) repair with or without additional retinaculum augmentation. Methods: We performed a retrospective review between 2017 and 2018 of 61 consecutive patients who underwent arthroscopic ATFL repair surgery for chronic ankle lateral instability. The exclusion criteria were previous surgery on affected ankle and combined medial ligament instability. Demographic data were evaluated including age, gender, smoking, Body mass index, generalized hyperlaxity and concomitant lesions. Patients were divided into two groups according to whether retinaculum repair or not. Clinical results were analysed to compare groups A and R preoperatively and at minimum follow-up of 1 years by using the Visual Analogue Scale, American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot and Ankle Outcome score (FAOS), and Karlsson Ankle Functional Score. Radiologic outcome evaluations were performed preoperatively and at 2 year postoperatively at final follow-up using anterior talar translation, and talar tilt angle. Results: A total of 62 patients were included in this study. Patients were divided into two groups: group A consisted of 29 patients who underwent only arthroscopic ATFL repair and group R consisted of 32 patients who underwent arthroscopic ATFL repair and additional retinaculum augmentation. There was no difference statistically between two group in demographics (Table 1). All clinical scores were improved after surgery in both groups. (P<0.001) There were no differences were found in VAS, AOFAS score, total FAOS and Karlsson score between two groups. However, sports activity unit in FAOS, there were significant differences between group A (71.4 +- 8.1) and group R (83.4 +- 8.6) (Table 2). (p=0.032) Radiographic data also showed no differences (Table 3). Conclusion: Arthroscopic ATFL repair achieved improved outcomes postoperatively with or without retinaculum augmentation. However, among physically active patients with chronic ankle lateral instability, arthroscopic ATFL repair with retinaculum augmentation results in better sports activity unit in FAOS as compare with arthroscopic ATFL repair alone.