ORIGINAL ARTICLE
Efficacy of the Modified Brostro¨m Procedure for Adolescent Patients With Chronic Lateral Ankle Instability Mininder S. Kocher, MD, MPH,*w Peter D. Fabricant, MD, MPH,* Adam Y. Nasreddine, MA,* Nicole Stenquist, BA,* Dennis E. Kramer, MD,*w and Jared T. Lee, MD*
Background and Purpose: Lateral ankle sprains are very common, representing up to 30% of sports-related injuries. The anterior talofibular ligament (ATFL) and less commonly the calcaneofibular ligament (CFL) are injured. Surgical treatment is reserved for injuries that fail nonoperative treatment with recurrent instability. Anatomic repair using the modified Brostro¨m technique has been shown to have good clinical outcomes in the adult population. The purpose of this study was to report on the outcomes of the modified Brostro¨m technique in the pediatric and adolescent population (under 18 y old) for chronic lateral ankle instability. Methods: Thirty-one patients over an 8-year period were included in the current study after excluding for congenital malformation or underlying connective tissue disease. All patients were treated with a modified Brostro¨m technique in which the ATFL was repaired anatomically. Twenty-four patients (77%) underwent concomitant arthroscopy for intra-articular pathology. Demographic, surgical, and clinical data were collected and outcome scores were obtained, including the Marx activity scale, University of California, Los Angeles (UCLA) activity score, and modified American Orthopedic Foot and Ankle Society (AOFAS) score. Results: Mean time from initial injury to surgery averaged 27 months with an overall mean clinical postoperative follow-up of 36 months. Of the 24 patients who underwent concomitant arthroscopy, all had thickening of Bassett ligament and 3 (12.5%) had cartilage lesions. Postoperatively, the mean Marx activity score was 9.9 ± 4.7, mean UCLA score was 9.3 ± 1.3, and mean modified AOFAS score was 83.8 ± 11.7. 71% (22 of 31) of patients achieved good-to-excellent results (as defined by a modified AOFAS score of 80 or greater). Two patients had superficial wound infections; no other complications were experienced in this cohort. Conclusions: Lateral ankle sprains are common injuries that can frequently be treated nonoperatively; chronic instability may result despite appropriate therapy. Surgical treatment with From the *Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children’s Hospital; and wDepartment of Orthopaedic Surgery, Harvard Medical School, Boston, MA. None of the authors received any external financial support. The authors declare no conflicts of interest. Reprints: Mininder S. Kocher, MD, MPH, Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Hunnewell 2, Boston, MA 02115. E-mail: [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
anatomic repair of the ATFL and CFL using the modified Brostro¨m technique in pediatric and adolescent patients results in improved stability, low complication rate, and good clinical outcome scores. Level of Evidence: Level IV—prognostic retrospective case series. Key Words: pediatric, adolescent, ATFL, CFL, Brostro¨m, Gould, outcome (J Pediatr Orthop 2015;00:000–000)
A
cute ankle sprains are the most common sports-related injury representing up to 30% of injuries.1 Lateral ankle sprains result in injury to the anterior talofibular ligament (ATFL) with variable involvement of the calcaneofibular ligament (CFL) and other capsuloligamentous structures. The ATFL is the primary restraint to inversion with increased stress as the ankle is in plantarflexion, whereas the CFL stabilizes the ankle and subtalar joints to inversion with the ankle in dorsiflexion.2 The severity of acute ankle sprains is graded based on the degree of ligamentous disruption and the ligaments involved.3 The majority of these injuries can be managed effectively with RICE (rest, ice, compression, and elevation therapy) and functional treatments such as proprioceptive training and peroneal strengthening.4 However, in up to 20% of patients, chronic instability of the lateral ankle develops despite adequate nonoperative treatment.5 Frequent episodes of “giving way” and recurrent ankle sprains despite adequate physical therapy and bracing are indications for surgery. Multiple surgical procedures have been described in the treatment of lateral ankle instability. These procedures have addressed the insufficiencies of the lateral ankle ligamentous complex, specifically the ATFL and CFL. They have been categorized as anatomic repairs,6–8 anatomic reconstructions,9,10 or nonanatomic reconstructions.11–13 Anatomic repair has been shown to have superior outcomes to nonanatomic reconstruction.14,15 In the adult population, anatomic repair using the modified Bro¨strom technique has shown good long-term outcomes and is frequently performed.16 In this study we report the outcomes of lateral ankle instability repair using the modified Brostro¨m technique in pediatric and adolescent patients. Our hypothesis is www.pedorthopaedics.com |
1
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Orthop
Kocher et al
that the modified Brostro¨m technique is an effective surgical treatment for chronic lateral ankle instability in the pediatric and adolescent patient.
METHODS An institutional review board–approved retrospective intradepartmental database review of electronic medical records at an urban tertiary care children’s hospital was conducted to identify patients 18 years old or younger who underwent a modified Bro¨strom procedure for lateral chronic ankle instability during the period from January 2000 through December 2010. All patients under age 18 at the time of surgery who underwent a modified Bro¨strom procedure and had at least 12 months of postoperative follow-up between surgery and their most recent clinical visit were considered for inclusion in the present study. Exclusion criteria were: incomplete clinical records, previous ankle surgery at an outside institution, and congenital malformation (eg, fibular hemimelia) or underlying connective tissue disorder (eg, Ehlers-Danlos syndrome). Patients who presented with recurrent ankle instability were indicated for surgery after clinical and radiographic evaluation and failure of nonoperative measures for a minimum of 4 months. Pertinent patient history included sensation of ankle instability or giving way, with or without mechanical symptoms and/or ankle pain. Physical examination findings that corroborated the patients’ history included positive anterior drawer and varus stress testing. Bony alignment including arch height and heel alignment were evaluated clinically. Clinical examination also included evaluation for symptomatic peroneal tendon subluxation. Ankle radiographs were evaluated to identify any bony abnormalities such as talar OCD lesions, avulsion fractures, or signs of tarsal coalition. Nonoperative measures included a minimum of 4 months of formal supervised physical therapy focusing on peroneal strengthening and proprioceptive training, and functional brace most often with a lace-up ankle brace for sports activities. Therapy notes were scrutinized to ensure adequate patient engagement. Before surgical intervention, ATFL and CFL abnormalities were identified with noncontrast MRI of the ankle, which also served to rule out other internal derangement of the ankle joint (eg, chondral lesions). In the event that the history, physical examination, or MRI identified intra-articular pathology (eg, anterolateral impingement, osteochondral lesion, etc.), a concomitant ankle arthroscopy was performed before open stabilization with treatment of pathology as noted at the time of surgery. At the time of surgery, examination under anesthesia confirmed ankle ligament laxity through anterior drawer and varus stress testing with results compared with the contralateral side. Clinical and demographic data collected from patients’ electronic medical records included: sex, age at the time of index surgery, primary sport at the time of injury, mechanism of injury, time from injury to surgery, concomitant procedures, revision surgery (if any), side of
2 | www.pedorthopaedics.com
Volume 00, Number 00, ’’ 2015
injury, and clinical follow-up calculated from the time of index surgery until the time of last clinical visit in months. All eligible patients completed 3 validated outcome measures: the Marx activity scale, University of California, Los Angeles (UCLA) activity scale, and the modified American Orthopedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot score at a mean of 36 months postoperatively. The Marx activity scale is a 4-item form intended to be used as a baseline measure of activity. The scale is designed to measure activity level rather than health status.17 The Marx scale is scored from 0 to 16, with the latter being indicative of high activity. The UCLA scale is a 10-level ordinal scale. The patient indicates her or his most appropriate activity level, with 1 defined as “no physical activity, dependent on others” and 10 defined as “regular participation in impact sports.”18 The modified AOFAS scoring system incorporates both subjective and objective factors into numeric scales to describe pain and function with a range of 0 to 100.19 Data were initially recorded in Microsoft Excel (Microsoft Corp., Redmond, WA) and was imported into SPSS (Version 19.0; SPSS Inc., Chicago, IL) software for statistical analysis. After assessing data for normality, descriptive statistics were used to report means and SDs for continuous variables, and frequencies for count variables. Comparative statistics were performed using independent samples Student t test to compare clinical outcome scores between males and females, and between those who underwent concomitant arthroscopy and those who did not. Because the current study is a report of all available patients, an a priori power calculation was not performed. P > 0.05 was used as the threshold for statistical significance.
Surgical Technique The original Brostro¨m procedure was described in 1966 as an anatomic primary repair for chronic ligament ruptures of the anterolateral ankle.6,20In the original description, the ATFL and CFL were repaired to the distal fibula using transosseous sutures to eliminate ligamentous redundancy due to chronic tearing and attenuation. Gould modified this technique to include incorporation of the extensor retinaculum tissue to augment the repair.7 For the technique used in this case series, a 4 to 5 cm curvilinear incision was made just anterior to the lateral malleolus. The proximal edge of the inferior extensor retinaculum was identified, incised, tagged, and reflected inferiorly, revealing the underlying ATFL and ankle joint capsule. The peroneal sheath was incised posterolaterally to inspect for peroneal tendinopathy. After retracting the peroneal tendons inferiorly, the CFL was visualized at the floor of the peroneal sheath. After identification of both structures (ATFL and CFL), the ATFL was divided transversely at its fibular origin and a #2 nonabsorbable braided suture was placed into its free fibular end using a modified Kessler tendon repair technique. The ATFL was then imbricated by advancing its fibular end and suturing it to the anterior fibular periosteum. In children with a Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
thin periosteal layer (13%; 4 of 31 patients), a suturethrough-bone technique was used to secure the ATFL to the fibula after lightly debriding the cortical bone of the distal fibula with a curette. The repair was reinforced with a figure-of-8 absorbable suture between the fibular periosteum and the free end of the ligament (Fig. 1). This same technique was used for CFL advancement. In the event the patient had symptomatic peroneal subluxation preoperatively, the technique was modified by transferring the CFL superficial to the peroneal tendons (6%; 2
Efficacy of Modified Brostro¨m in Adolescents
of 31 patients). A Gould modification was then performed by advancing the previously tagged extensor retinaculum to the fibular periosteum with absorbable suture to augment the repair. Postoperatively, patients were immobilized in a plaster splint, short-leg cast, or boot and were non– weight-bearing for 2 to 4 weeks. Following initial immobilization, patients were transitioned into a walking boot with progressive weight-bearing as tolerated and began physical therapy for sagittal plane range of motion.
FIGURE 1. Demonstration of the surgical technique used in the current study. Brostro¨m-Gould ankle reconstruction surgery. Incision (A), damaged ligaments (B); division of ligaments at fibular origin (C), anatomic repair of ligaments (D); and inferior extensor retinaculum sutured to anterior distal fibula (E). Image reprinted with permission, copyright MediVisuals Inc. Copyright [MediVisuals Inc.], Richmond, VA. All permission requests for this image should be made to the copyright holder. Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
www.pedorthopaedics.com |
3
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Orthop
Kocher et al
At 6 to 8 weeks, the boot was discontinued and a lace-up brace was used for support. Physical therapy was then increased to include inversion/eversion range of motion, proprioception, peroneal strengthening, and sport-specific strengthening. At 3 months, patients were allowed to gradually return to sport activities with a lace-up ankle brace.
RESULTS Of 47 consecutive patients who underwent a Brostro¨m surgery for chronic lateral ankle instability during the study period, 3 were excluded for underlying connective tissue disease or congenital abnormality (1 EhlersDanlos, 1 neurofibromatosis, and 1 fibular hemimelia on the affected side), leaving 44 patients for potential inclusion. Thirty-one of these patients (70.5%) had complete medical records including clinical outcomes scores, and were included in the final analysis (Table 1). Twenty-six (84%) were female; the mean age at the time of index surgery was 14.9 ± 2.7 years old. The mean time from initial injury to surgery averaged 27 months with an overall mean clinical postoperative follow-up of 36.2 ± 17.1 months. The most common sport played was soccer (35%; 11 of 31 patients); sports played by the study cohort are shown in (Table 2). Twenty-four (77%) of patients had a concomitant arthroscopy before modified Brostro¨m. Of those, all 24 were found to have hypertrophic anterolatereal synovium and a thickened, fibrotic Bassett ligament which were debrided. Three patients (10%) had cartilage lesions, 2 of which were treated with chondroplasty and microfracture and one of which was treated with chondroplasty alone. Two patients (6%) underwent CFL transfer for symptomatic peroneal tendon subluxation, which consisted of a slight technique modification whereby the CFL was transferred to the fibula superficial to the peroneal tendons rather than deep to them. Mean tourniquet time was 71 ± 25 minutes.
Mean ± SD
Age Follow-up (mo) Sex (female) Side (left) Arthroscopy Debridement of Bassett ligament Chondroplasty/microfracture Chondroplasty Clinical outcome scores Marx UCLA Modified AOFAS
14.9 ± 2.7 36.2 ± 17.1
Count [n (%)]
26 14 24 24 2 1
(84) (45) (77) (100) (8) (4)
9.9 ± 4.7 9.3 ± 1.3 83.8 ± 11.7
Percentages of arthroscopic procedures calculated only for those who underwent arthroscopy. AOFAS indicates American Orthopedic Foot and Ankle Society; UCLA, University of California, Los Angeles.
4 | www.pedorthopaedics.com
Volume 00, Number 00, ’’ 2015
TABLE 2. Primary Sport Played by Patients in the Study Cohort Sport
Count [n (%)]
Soccer Basketball Softball Dance Volleyball Football Tennis Gymnastics Skiing Other None
11 4 2 2 2 1 1 1 1 3 3
(35) (13) (6) (6) (6) (3) (3) (3) (3) (10) (10)
Percentages rounded to the nearest whole number.
In the study group,1 patient had persistent pain laterally and subtalar laxity with the ankle dorsiflexed. Two of the 31 patients (6%) experienced wound complications 4 weeks postoperatively. The first patient underwent surgical irrigation and debridement. The culture was positive for mixed flora including Peptostreptoccus, Pseudomonas, and Serratia species. The patient was successfully treated with clindamycin. The second patient had complete resolution with a 10-day course of oral antibiotic (cephalexin). There were no other complications. With regard to clinical outcome scores, the mean Marx activity score was 9.9 ± 4.7, mean UCLA score was 9.3 ± 1.3, and mean modified AOFAS score was 83.8 ± 11.7. Good-to-excellent results (as defined by a modified AOFAS score of 80 or greater)21–24 were achieved in 71% (22 of 31) of patients. There were no significant differences in the mean Marx, UCLA, and AOFAS scores when comparing patients who had concomitant arthroscopy and those who did not (P > 0.05 for all). Likewise, there were no differences in any of the clinical outcome scores between males and females (P > 0.05 for all).
DISCUSSION
TABLE 1. Demographics, Surgical Data, and Clinical Outcome Scores in the Study Cohort Variables
Similar to other pediatric musculoskeletal injuries, the incidence of ankle sprains has risen with increased sports participation in the pediatric population. The indication for surgical treatment of chronic lateral ankle instability is persistent instability despite an appropriate supervised course of physical therapy concentrating on proprioception and peroneal strengthening. The choice of a modified Brostro¨m for our patients was based on the principles of repairing or reconstructing ligamentous structures anatomically. In addition, the modified Brostro¨m procedure has been shown to have good outcomes in the adult population by many authors.8,16,25 Other techniques for treatment of lateral ligament injury in the pediatric population have been published including the modified Chrisman-Snook. The ChrismanSnook procedure is a nonanatomic reconstruction utilizing a portion of the peroneus brevis tendon and routing Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
this slip of tendon through a bone tunnel in the distal fibula. Marsh et al26 reported on 48 modified ChrismanSnook procedures in the pediatric population (age 8 to 17 y) at a mean follow-up of 6.5 years. They found a high patient satisfaction with average function reported as 8/10. Later, Yang and colleagues reported their 2-year results of the modified Chrisman-Snook reconstruction in 53 surgeries with good results. All patients had resolution of pain and were able to return to their previous activity level. However, 2 sural nerve neuromas developed requiring surgery and 23% had recurrent sprains, all of which were managed nonoperatively.27 Some of the potential risks of a nonanatomic reconstruction are injury to the distal fibular physis, weakening of the peroneal tendons, and tethering of the distal fibular physis resulting in growth disturbance. Our series includes patients starting at the age of 9, which is similar to Marsh’s series that included patients as young as 8 years old. Physeal injury is a concern in the younger patient with the added risk of a possible tethering effect on the distal fibular physis from the nonanatomic graft. Although a modified ChrismanSnook has been shown to be an effective treatment for lateral ankle instability in the pediatric population, we feel it is best reserved for cases of ATFL attenuation in which a modified Brostro¨m is not feasible. This mirrors the recommendations found in the adult literature.14,28 The current study shows good-to-excellent results in 71% of patients based on the AOFAS score. These outcomes are similar to those of previous authors who reported their outcomes in an adult patient population. Karlsson et al8 in their series reported good-to-excellent results in 87% of patients. Patient outcomes were categorized as poor, fair, good, or excellent and used the criteria previously described by Sefton et al.29 An excellent result was given if the patient was able to return to full activity, including strenuous sport without pain, instability, or swelling. A good result was given if there was a full return to activity without instability but pain or swelling. Bell et al16 reported good-to-excellent results in 91% of patients treated with a Brostro¨m procedure according to the scale described by Good et al.30 Although the mean AOFAS score in the current study was slightly lower than those reported in the adult literature, our patients’ postoperative activity scores were high. The mean UCLA activity score was 9 on a 10-point scale, which denotes impact of sports participation on a semiregular basis. The mean Marx activity scale was 10 out of 16. It is possible that the modest AOFAS scores in the context of elevated activity scores is secondary to pain, rather than instability, in a few patients despite high activity levels. It should be noted that no patients required revision surgery despite 6 patients being categorized as having a fair or poor outcome based on their modified AOFAS score. Our indications for revision surgery include recurrent symptomatic instability limiting function and sports participation. Although the modified AOFAS patient-reported outcome score indicated 9 patients with fair or poor results, none of these had symptomatic recurrent instability meeting criteria for revision surgery. Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Efficacy of Modified Brostro¨m in Adolescents
Limitations of the study include in addition to its retrospective nature, a 70.5% response rate to outcome questionnaires, limited patient population, no radiographic follow-up examinations, and no preoperative baseline outcome scores for statistical comparison. With regard to the retrospective study design and 29% loss to follow up, this potential for selection bias is inherent to nearly all retrospective studies. Of the 29% of patients who did not complete the questionnaire, none had major complications or recurrent surgeries per their medical records at a mean follow-up of 3.4 ± 2.0 years. It is possible that those who were lost to follow-up may have had poor outcomes and sought care elsewhere, or had excellent outcomes and likewise did not follow-up. A limitation of performing clinical outcomes research in children and adolescents is that this demographic frequently moves for school/university attendance and easily becomes lost to follow-up. In the current study, we are unaware of any factors that would lead to differential loss to follow-up between those that may have had successful or unsuccessful surgery, and therefore believe that a 70.5% response rate is unlikely to represent a significant selection bias. Although radiographs may have been helpful, it is our practice to defer radiographic follow-up given the radiation exposure in the pediatric population and are not likely to show degenerative changes until several years after injury. Finally, the 3 patient-reported outcomes used in the current study were not specifically validated in children. To our knowledge, there are no pediatric-specific foot and ankle outcomes measures. Currently, there is a pediatric version of the IKDC knee outcome score31 and 1 pediatric sports activity rating scale that was not available at the time of the current study.32 The outcome measures used in the current study were the best available at the time of data collection. Further development and validation of pediatric-specific patient-reported outcomes is an area of current research interest.
CONCLUSIONS Lateral ankle instability requiring surgical intervention is increasingly seen in the pediatric and adolescent population. Although multiple surgical treatment options are available for lateral ligament repair or reconstruction, we prefer a modified Brostro¨m as it is an anatomic repair that does not risk injury to the distal fibular physis or weakening of the peroneal tendons. The modified Brostro¨m is well tolerated with a low complication rate and the majority of patients can expect good-to-excellent result with a high postoperative activity level. REFERENCES 1. Perlman M, Leveille D, DeLeonibus J, et al. Inversion lateral ankle trauma: differential diagnosis, review of the literature, and prospective study. J Foot Surg. 1987;26:95–135. 2. Colville MR, Marder RA, Boyle JJ, et al. Strain measurement in lateral ankle ligaments. Am J Sports Med. 1990;18:196–200. 3. Chorley JN, Hergenroeder AC. Management of ankle sprains. Pediatr Ann. 1997;26:56–64. 4. van Rijn RM, van Os AG, Bernsen RM, et al. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med. 2008;121:324.e6–331.e6.
www.pedorthopaedics.com |
5
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Kocher et al
5. Krips R, de Vries J, van Dijk CN. Ankle instability. Foot Ankle Clin. 2006;11:311–329. vi. 6. Brostrom L. Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures. Acta Chir Scand. 1966;132:551–565. 7. Gould N, Seligson D, Gassman J. Early and late repair of lateral ligament of the ankle. Foot Ankle. 1980;1:84–89. 8. Karlsson J, Bergsten T, Lansinger O, et al. Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg Am. 1988;70:581–588. 9. Caprio A, Oliva F, Treia F, et al. Reconstruction of the lateral ankle ligaments with allograft in patients with chronic ankle instability. Foot Ankle Clin. 2006;11:597–605. 10. Pagenstert GI, Hintermann B, Knupp M. Operative management of chronic ankle instability: plantaris graft. Foot Ankle Clin. 2006;11: 567–583. 11. Chrisman OD, Snook GA. Reconstruction of lateral ligament tears of the ankle. An experimental study and clinical evaluation of seven patients treated by a new modification of the Elmslie procedure. J Bone Joint Surg Am. 1969;51:904–912. 12. Evans DL. Recurrent instability of the ankle; a method of surgical treatment. Proc R Soc Med. 1953;46:343–344. 13. Watson-Jones R. The classic: “Fractures and Joint Injuries” by Sir Reginald Watson-Jones, taken from “Fractures and Joint Injuries,” by R. Watson-Jones, Vol. II, 4th ed., Baltimore, Williams and Wilkins Company, 1955. Clin Orthop Relat Res. 1974;105:4–10. 14. Hennrikus WL, Mapes RC, Lyons PM, et al. Outcomes of the Chrisman-Snook and modified-Brostrom procedures for chronic lateral ankle instability. A prospective, randomized comparison. Am J Sports Med. 1996;24:400–404. 15. Krips R, Brandsson S, Swensson C, et al. Anatomical reconstruction and Evans tenodesis of the lateral ligaments of the ankle. Clinical and radiological findings after follow-up for 15 to 30 years. J Bone Joint Surg Br. 2002;84:232–236. 16. Bell SJ, Mologne TS, Sitler DF, et al. Twenty-six-year results after Brostrom procedure for chronic lateral ankle instability. Am J Sports Med. 2006;34:975–978. 17. Marx RG, Stump TJ, Jones EC, et al. Development and evaluation of an activity rating scale for disorders of the knee. Am J Sports Med. 2001;29:213–218. 18. Naal FD, Impellizzeri FM, Leunig M. Which is the best activity rating scale for patients undergoing total joint arthroplasty? Clin Orthop Relat Res. 2009;467:958–965.
6 | www.pedorthopaedics.com
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
19. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15:349–353. 20. Brostrom L. Sprained ankles. V. Treatment and prognosis in recent ligament ruptures. Acta Chir Scand. 1966;132:537–550. 21. Chen CY, Huang PJ, Kao KF, et al. Surgical reconstruction for chronic lateral instability of the ankle. Injury. 2004;35:809–813. 22. Giannini S, Buda R, Vannini F, et al. Arthroscopic autologous chondrocyte implantation in osteochondral lesions of the talus: surgical technique and results. Am J Sports Med. 2008;36:873–880. 23. Giannini S, Ruffilli A, Pagliazzi G, et al. Treatment algorithm for chronic lateral ankle instability. Muscles Ligaments Tendons J. 2014; 4:455–460. 24. Hu CY, Lee KB, Song EK, et al. Comparison of bone tunnel and suture anchor techniques in the modified Brostrom procedure for chronic lateral ankle instability. Am J Sports Med. 2013;41:1877–1884. 25. Buerer Y, Winkler M, Burn A, et al. Evaluation of a modified Brostrom-Gould procedure for treatment of chronic lateral ankle instability: a retrospective study with critical analysis of outcome scoring. Foot Ankle Surg. 2013;19:36–41. 26. Marsh JS, Daigneault JP, Polzhofer GK. Treatment of ankle instability in children and adolescents with a modified ChrismanSnook repair: a clinical and patient-based outcome study. J Pediatr Orthop. 2006;26:94–99. 27. Yang J Jr, Morscher MA, Weiner DS. Modified Chrisman-Snook repair for the treatment of chronic ankle ligamentous instability in children and adolescents. J Child Orthop. 2010;4:561–570. 28. Baumhauer JF, O’Brien T. Surgical considerations in the treatment of ankle instability. J Athl Train. 2002;37:458–462. 29. Sefton GK, George J, Fitton JM, et al. Reconstruction of the anterior talofibular ligament for the treatment of the unstable ankle. J Bone Joint Surg Br. 1979;61-B:352–354. 30. Good CJ, Jones MA, Lingstone BN. Reconstruction of the lateral ligament of the ankle. Injury. 1975;7:63–65. 31. Kocher MS, Smith JT, Iversen MD, et al. Reliability, validity, and responsiveness of a modified International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC) in children with knee disorders. Am J Sports Med. 2011;39:933–939. 32. Fabricant PD, Robles A, Downey-Zayas T, et al. Development and validation of a pediatric sports activity rating scale: the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS PediFABS). Am J Sports Med. 2013;41:2421–2429.
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Efficacy of the Modified Brostro¨m Procedure for Adolescent Patients With Chronic Lateral Ankle Instability Mininder S. Kocher, MD, MPH,*w Peter D. Fabricant, MD, MPH,* Adam Y. Nasreddine, MA,* Nicole Stenquist, BA,* Dennis E. Kramer, MD,*w and Jared T. Lee, MD*
Background and Purpose: Lateral ankle sprains are very common, representing up to 30% of sports-related injuries. The anterior talofibular ligament (ATFL) and less commonly the calcaneofibular ligament (CFL) are injured. Surgical treatment is reserved for injuries that fail nonoperative treatment with recurrent instability. Anatomic repair using the modified Brostro¨m technique has been shown to have good clinical outcomes in the adult population. The purpose of this study was to report on the outcomes of the modified Brostro¨m technique in the pediatric and adolescent population (under 18 y old) for chronic lateral ankle instability. Methods: Thirty-one patients over an 8-year period were included in the current study after excluding for congenital malformation or underlying connective tissue disease. All patients were treated with a modified Brostro¨m technique in which the ATFL was repaired anatomically. Twenty-four patients (77%) underwent concomitant arthroscopy for intra-articular pathology. Demographic, surgical, and clinical data were collected and outcome scores were obtained, including the Marx activity scale, University of California, Los Angeles (UCLA) activity score, and modified American Orthopedic Foot and Ankle Society (AOFAS) score. Results: Mean time from initial injury to surgery averaged 27 months with an overall mean clinical postoperative follow-up of 36 months. Of the 24 patients who underwent concomitant arthroscopy, all had thickening of Bassett ligament and 3 (12.5%) had cartilage lesions. Postoperatively, the mean Marx activity score was 9.9 ± 4.7, mean UCLA score was 9.3 ± 1.3, and mean modified AOFAS score was 83.8 ± 11.7. 71% (22 of 31) of patients achieved good-to-excellent results (as defined by a modified AOFAS score of 80 or greater). Two patients had superficial wound infections; no other complications were experienced in this cohort. Conclusions: Lateral ankle sprains are common injuries that can frequently be treated nonoperatively; chronic instability may result despite appropriate therapy. Surgical treatment with From the *Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children’s Hospital; and wDepartment of Orthopaedic Surgery, Harvard Medical School, Boston, MA. None of the authors received any external financial support. The authors declare no conflicts of interest. Reprints: Mininder S. Kocher, MD, MPH, Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Hunnewell 2, Boston, MA 02115. E-mail: [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
anatomic repair of the ATFL and CFL using the modified Brostro¨m technique in pediatric and adolescent patients results in improved stability, low complication rate, and good clinical outcome scores. Level of Evidence: Level IV—prognostic retrospective case series. Key Words: pediatric, adolescent, ATFL, CFL, Brostro¨m, Gould, outcome (J Pediatr Orthop 2015;00:000–000)
A
cute ankle sprains are the most common sports-related injury representing up to 30% of injuries.1 Lateral ankle sprains result in injury to the anterior talofibular ligament (ATFL) with variable involvement of the calcaneofibular ligament (CFL) and other capsuloligamentous structures. The ATFL is the primary restraint to inversion with increased stress as the ankle is in plantarflexion, whereas the CFL stabilizes the ankle and subtalar joints to inversion with the ankle in dorsiflexion.2 The severity of acute ankle sprains is graded based on the degree of ligamentous disruption and the ligaments involved.3 The majority of these injuries can be managed effectively with RICE (rest, ice, compression, and elevation therapy) and functional treatments such as proprioceptive training and peroneal strengthening.4 However, in up to 20% of patients, chronic instability of the lateral ankle develops despite adequate nonoperative treatment.5 Frequent episodes of “giving way” and recurrent ankle sprains despite adequate physical therapy and bracing are indications for surgery. Multiple surgical procedures have been described in the treatment of lateral ankle instability. These procedures have addressed the insufficiencies of the lateral ankle ligamentous complex, specifically the ATFL and CFL. They have been categorized as anatomic repairs,6–8 anatomic reconstructions,9,10 or nonanatomic reconstructions.11–13 Anatomic repair has been shown to have superior outcomes to nonanatomic reconstruction.14,15 In the adult population, anatomic repair using the modified Bro¨strom technique has shown good long-term outcomes and is frequently performed.16 In this study we report the outcomes of lateral ankle instability repair using the modified Brostro¨m technique in pediatric and adolescent patients. Our hypothesis is www.pedorthopaedics.com |
1
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Orthop
Kocher et al
that the modified Brostro¨m technique is an effective surgical treatment for chronic lateral ankle instability in the pediatric and adolescent patient.
METHODS An institutional review board–approved retrospective intradepartmental database review of electronic medical records at an urban tertiary care children’s hospital was conducted to identify patients 18 years old or younger who underwent a modified Bro¨strom procedure for lateral chronic ankle instability during the period from January 2000 through December 2010. All patients under age 18 at the time of surgery who underwent a modified Bro¨strom procedure and had at least 12 months of postoperative follow-up between surgery and their most recent clinical visit were considered for inclusion in the present study. Exclusion criteria were: incomplete clinical records, previous ankle surgery at an outside institution, and congenital malformation (eg, fibular hemimelia) or underlying connective tissue disorder (eg, Ehlers-Danlos syndrome). Patients who presented with recurrent ankle instability were indicated for surgery after clinical and radiographic evaluation and failure of nonoperative measures for a minimum of 4 months. Pertinent patient history included sensation of ankle instability or giving way, with or without mechanical symptoms and/or ankle pain. Physical examination findings that corroborated the patients’ history included positive anterior drawer and varus stress testing. Bony alignment including arch height and heel alignment were evaluated clinically. Clinical examination also included evaluation for symptomatic peroneal tendon subluxation. Ankle radiographs were evaluated to identify any bony abnormalities such as talar OCD lesions, avulsion fractures, or signs of tarsal coalition. Nonoperative measures included a minimum of 4 months of formal supervised physical therapy focusing on peroneal strengthening and proprioceptive training, and functional brace most often with a lace-up ankle brace for sports activities. Therapy notes were scrutinized to ensure adequate patient engagement. Before surgical intervention, ATFL and CFL abnormalities were identified with noncontrast MRI of the ankle, which also served to rule out other internal derangement of the ankle joint (eg, chondral lesions). In the event that the history, physical examination, or MRI identified intra-articular pathology (eg, anterolateral impingement, osteochondral lesion, etc.), a concomitant ankle arthroscopy was performed before open stabilization with treatment of pathology as noted at the time of surgery. At the time of surgery, examination under anesthesia confirmed ankle ligament laxity through anterior drawer and varus stress testing with results compared with the contralateral side. Clinical and demographic data collected from patients’ electronic medical records included: sex, age at the time of index surgery, primary sport at the time of injury, mechanism of injury, time from injury to surgery, concomitant procedures, revision surgery (if any), side of
2 | www.pedorthopaedics.com
Volume 00, Number 00, ’’ 2015
injury, and clinical follow-up calculated from the time of index surgery until the time of last clinical visit in months. All eligible patients completed 3 validated outcome measures: the Marx activity scale, University of California, Los Angeles (UCLA) activity scale, and the modified American Orthopedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot score at a mean of 36 months postoperatively. The Marx activity scale is a 4-item form intended to be used as a baseline measure of activity. The scale is designed to measure activity level rather than health status.17 The Marx scale is scored from 0 to 16, with the latter being indicative of high activity. The UCLA scale is a 10-level ordinal scale. The patient indicates her or his most appropriate activity level, with 1 defined as “no physical activity, dependent on others” and 10 defined as “regular participation in impact sports.”18 The modified AOFAS scoring system incorporates both subjective and objective factors into numeric scales to describe pain and function with a range of 0 to 100.19 Data were initially recorded in Microsoft Excel (Microsoft Corp., Redmond, WA) and was imported into SPSS (Version 19.0; SPSS Inc., Chicago, IL) software for statistical analysis. After assessing data for normality, descriptive statistics were used to report means and SDs for continuous variables, and frequencies for count variables. Comparative statistics were performed using independent samples Student t test to compare clinical outcome scores between males and females, and between those who underwent concomitant arthroscopy and those who did not. Because the current study is a report of all available patients, an a priori power calculation was not performed. P > 0.05 was used as the threshold for statistical significance.
Surgical Technique The original Brostro¨m procedure was described in 1966 as an anatomic primary repair for chronic ligament ruptures of the anterolateral ankle.6,20In the original description, the ATFL and CFL were repaired to the distal fibula using transosseous sutures to eliminate ligamentous redundancy due to chronic tearing and attenuation. Gould modified this technique to include incorporation of the extensor retinaculum tissue to augment the repair.7 For the technique used in this case series, a 4 to 5 cm curvilinear incision was made just anterior to the lateral malleolus. The proximal edge of the inferior extensor retinaculum was identified, incised, tagged, and reflected inferiorly, revealing the underlying ATFL and ankle joint capsule. The peroneal sheath was incised posterolaterally to inspect for peroneal tendinopathy. After retracting the peroneal tendons inferiorly, the CFL was visualized at the floor of the peroneal sheath. After identification of both structures (ATFL and CFL), the ATFL was divided transversely at its fibular origin and a #2 nonabsorbable braided suture was placed into its free fibular end using a modified Kessler tendon repair technique. The ATFL was then imbricated by advancing its fibular end and suturing it to the anterior fibular periosteum. In children with a Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
thin periosteal layer (13%; 4 of 31 patients), a suturethrough-bone technique was used to secure the ATFL to the fibula after lightly debriding the cortical bone of the distal fibula with a curette. The repair was reinforced with a figure-of-8 absorbable suture between the fibular periosteum and the free end of the ligament (Fig. 1). This same technique was used for CFL advancement. In the event the patient had symptomatic peroneal subluxation preoperatively, the technique was modified by transferring the CFL superficial to the peroneal tendons (6%; 2
Efficacy of Modified Brostro¨m in Adolescents
of 31 patients). A Gould modification was then performed by advancing the previously tagged extensor retinaculum to the fibular periosteum with absorbable suture to augment the repair. Postoperatively, patients were immobilized in a plaster splint, short-leg cast, or boot and were non– weight-bearing for 2 to 4 weeks. Following initial immobilization, patients were transitioned into a walking boot with progressive weight-bearing as tolerated and began physical therapy for sagittal plane range of motion.
FIGURE 1. Demonstration of the surgical technique used in the current study. Brostro¨m-Gould ankle reconstruction surgery. Incision (A), damaged ligaments (B); division of ligaments at fibular origin (C), anatomic repair of ligaments (D); and inferior extensor retinaculum sutured to anterior distal fibula (E). Image reprinted with permission, copyright MediVisuals Inc. Copyright [MediVisuals Inc.], Richmond, VA. All permission requests for this image should be made to the copyright holder. Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
www.pedorthopaedics.com |
3
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Orthop
Kocher et al
At 6 to 8 weeks, the boot was discontinued and a lace-up brace was used for support. Physical therapy was then increased to include inversion/eversion range of motion, proprioception, peroneal strengthening, and sport-specific strengthening. At 3 months, patients were allowed to gradually return to sport activities with a lace-up ankle brace.
RESULTS Of 47 consecutive patients who underwent a Brostro¨m surgery for chronic lateral ankle instability during the study period, 3 were excluded for underlying connective tissue disease or congenital abnormality (1 EhlersDanlos, 1 neurofibromatosis, and 1 fibular hemimelia on the affected side), leaving 44 patients for potential inclusion. Thirty-one of these patients (70.5%) had complete medical records including clinical outcomes scores, and were included in the final analysis (Table 1). Twenty-six (84%) were female; the mean age at the time of index surgery was 14.9 ± 2.7 years old. The mean time from initial injury to surgery averaged 27 months with an overall mean clinical postoperative follow-up of 36.2 ± 17.1 months. The most common sport played was soccer (35%; 11 of 31 patients); sports played by the study cohort are shown in (Table 2). Twenty-four (77%) of patients had a concomitant arthroscopy before modified Brostro¨m. Of those, all 24 were found to have hypertrophic anterolatereal synovium and a thickened, fibrotic Bassett ligament which were debrided. Three patients (10%) had cartilage lesions, 2 of which were treated with chondroplasty and microfracture and one of which was treated with chondroplasty alone. Two patients (6%) underwent CFL transfer for symptomatic peroneal tendon subluxation, which consisted of a slight technique modification whereby the CFL was transferred to the fibula superficial to the peroneal tendons rather than deep to them. Mean tourniquet time was 71 ± 25 minutes.
Mean ± SD
Age Follow-up (mo) Sex (female) Side (left) Arthroscopy Debridement of Bassett ligament Chondroplasty/microfracture Chondroplasty Clinical outcome scores Marx UCLA Modified AOFAS
14.9 ± 2.7 36.2 ± 17.1
Count [n (%)]
26 14 24 24 2 1
(84) (45) (77) (100) (8) (4)
9.9 ± 4.7 9.3 ± 1.3 83.8 ± 11.7
Percentages of arthroscopic procedures calculated only for those who underwent arthroscopy. AOFAS indicates American Orthopedic Foot and Ankle Society; UCLA, University of California, Los Angeles.
4 | www.pedorthopaedics.com
Volume 00, Number 00, ’’ 2015
TABLE 2. Primary Sport Played by Patients in the Study Cohort Sport
Count [n (%)]
Soccer Basketball Softball Dance Volleyball Football Tennis Gymnastics Skiing Other None
11 4 2 2 2 1 1 1 1 3 3
(35) (13) (6) (6) (6) (3) (3) (3) (3) (10) (10)
Percentages rounded to the nearest whole number.
In the study group,1 patient had persistent pain laterally and subtalar laxity with the ankle dorsiflexed. Two of the 31 patients (6%) experienced wound complications 4 weeks postoperatively. The first patient underwent surgical irrigation and debridement. The culture was positive for mixed flora including Peptostreptoccus, Pseudomonas, and Serratia species. The patient was successfully treated with clindamycin. The second patient had complete resolution with a 10-day course of oral antibiotic (cephalexin). There were no other complications. With regard to clinical outcome scores, the mean Marx activity score was 9.9 ± 4.7, mean UCLA score was 9.3 ± 1.3, and mean modified AOFAS score was 83.8 ± 11.7. Good-to-excellent results (as defined by a modified AOFAS score of 80 or greater)21–24 were achieved in 71% (22 of 31) of patients. There were no significant differences in the mean Marx, UCLA, and AOFAS scores when comparing patients who had concomitant arthroscopy and those who did not (P > 0.05 for all). Likewise, there were no differences in any of the clinical outcome scores between males and females (P > 0.05 for all).
DISCUSSION
TABLE 1. Demographics, Surgical Data, and Clinical Outcome Scores in the Study Cohort Variables
Similar to other pediatric musculoskeletal injuries, the incidence of ankle sprains has risen with increased sports participation in the pediatric population. The indication for surgical treatment of chronic lateral ankle instability is persistent instability despite an appropriate supervised course of physical therapy concentrating on proprioception and peroneal strengthening. The choice of a modified Brostro¨m for our patients was based on the principles of repairing or reconstructing ligamentous structures anatomically. In addition, the modified Brostro¨m procedure has been shown to have good outcomes in the adult population by many authors.8,16,25 Other techniques for treatment of lateral ligament injury in the pediatric population have been published including the modified Chrisman-Snook. The ChrismanSnook procedure is a nonanatomic reconstruction utilizing a portion of the peroneus brevis tendon and routing Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
this slip of tendon through a bone tunnel in the distal fibula. Marsh et al26 reported on 48 modified ChrismanSnook procedures in the pediatric population (age 8 to 17 y) at a mean follow-up of 6.5 years. They found a high patient satisfaction with average function reported as 8/10. Later, Yang and colleagues reported their 2-year results of the modified Chrisman-Snook reconstruction in 53 surgeries with good results. All patients had resolution of pain and were able to return to their previous activity level. However, 2 sural nerve neuromas developed requiring surgery and 23% had recurrent sprains, all of which were managed nonoperatively.27 Some of the potential risks of a nonanatomic reconstruction are injury to the distal fibular physis, weakening of the peroneal tendons, and tethering of the distal fibular physis resulting in growth disturbance. Our series includes patients starting at the age of 9, which is similar to Marsh’s series that included patients as young as 8 years old. Physeal injury is a concern in the younger patient with the added risk of a possible tethering effect on the distal fibular physis from the nonanatomic graft. Although a modified ChrismanSnook has been shown to be an effective treatment for lateral ankle instability in the pediatric population, we feel it is best reserved for cases of ATFL attenuation in which a modified Brostro¨m is not feasible. This mirrors the recommendations found in the adult literature.14,28 The current study shows good-to-excellent results in 71% of patients based on the AOFAS score. These outcomes are similar to those of previous authors who reported their outcomes in an adult patient population. Karlsson et al8 in their series reported good-to-excellent results in 87% of patients. Patient outcomes were categorized as poor, fair, good, or excellent and used the criteria previously described by Sefton et al.29 An excellent result was given if the patient was able to return to full activity, including strenuous sport without pain, instability, or swelling. A good result was given if there was a full return to activity without instability but pain or swelling. Bell et al16 reported good-to-excellent results in 91% of patients treated with a Brostro¨m procedure according to the scale described by Good et al.30 Although the mean AOFAS score in the current study was slightly lower than those reported in the adult literature, our patients’ postoperative activity scores were high. The mean UCLA activity score was 9 on a 10-point scale, which denotes impact of sports participation on a semiregular basis. The mean Marx activity scale was 10 out of 16. It is possible that the modest AOFAS scores in the context of elevated activity scores is secondary to pain, rather than instability, in a few patients despite high activity levels. It should be noted that no patients required revision surgery despite 6 patients being categorized as having a fair or poor outcome based on their modified AOFAS score. Our indications for revision surgery include recurrent symptomatic instability limiting function and sports participation. Although the modified AOFAS patient-reported outcome score indicated 9 patients with fair or poor results, none of these had symptomatic recurrent instability meeting criteria for revision surgery. Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Efficacy of Modified Brostro¨m in Adolescents
Limitations of the study include in addition to its retrospective nature, a 70.5% response rate to outcome questionnaires, limited patient population, no radiographic follow-up examinations, and no preoperative baseline outcome scores for statistical comparison. With regard to the retrospective study design and 29% loss to follow up, this potential for selection bias is inherent to nearly all retrospective studies. Of the 29% of patients who did not complete the questionnaire, none had major complications or recurrent surgeries per their medical records at a mean follow-up of 3.4 ± 2.0 years. It is possible that those who were lost to follow-up may have had poor outcomes and sought care elsewhere, or had excellent outcomes and likewise did not follow-up. A limitation of performing clinical outcomes research in children and adolescents is that this demographic frequently moves for school/university attendance and easily becomes lost to follow-up. In the current study, we are unaware of any factors that would lead to differential loss to follow-up between those that may have had successful or unsuccessful surgery, and therefore believe that a 70.5% response rate is unlikely to represent a significant selection bias. Although radiographs may have been helpful, it is our practice to defer radiographic follow-up given the radiation exposure in the pediatric population and are not likely to show degenerative changes until several years after injury. Finally, the 3 patient-reported outcomes used in the current study were not specifically validated in children. To our knowledge, there are no pediatric-specific foot and ankle outcomes measures. Currently, there is a pediatric version of the IKDC knee outcome score31 and 1 pediatric sports activity rating scale that was not available at the time of the current study.32 The outcome measures used in the current study were the best available at the time of data collection. Further development and validation of pediatric-specific patient-reported outcomes is an area of current research interest.
CONCLUSIONS Lateral ankle instability requiring surgical intervention is increasingly seen in the pediatric and adolescent population. Although multiple surgical treatment options are available for lateral ligament repair or reconstruction, we prefer a modified Brostro¨m as it is an anatomic repair that does not risk injury to the distal fibular physis or weakening of the peroneal tendons. The modified Brostro¨m is well tolerated with a low complication rate and the majority of patients can expect good-to-excellent result with a high postoperative activity level. REFERENCES 1. Perlman M, Leveille D, DeLeonibus J, et al. Inversion lateral ankle trauma: differential diagnosis, review of the literature, and prospective study. J Foot Surg. 1987;26:95–135. 2. Colville MR, Marder RA, Boyle JJ, et al. Strain measurement in lateral ankle ligaments. Am J Sports Med. 1990;18:196–200. 3. Chorley JN, Hergenroeder AC. Management of ankle sprains. Pediatr Ann. 1997;26:56–64. 4. van Rijn RM, van Os AG, Bernsen RM, et al. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med. 2008;121:324.e6–331.e6.
www.pedorthopaedics.com |
5
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Kocher et al
5. Krips R, de Vries J, van Dijk CN. Ankle instability. Foot Ankle Clin. 2006;11:311–329. vi. 6. Brostrom L. Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures. Acta Chir Scand. 1966;132:551–565. 7. Gould N, Seligson D, Gassman J. Early and late repair of lateral ligament of the ankle. Foot Ankle. 1980;1:84–89. 8. Karlsson J, Bergsten T, Lansinger O, et al. Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg Am. 1988;70:581–588. 9. Caprio A, Oliva F, Treia F, et al. Reconstruction of the lateral ankle ligaments with allograft in patients with chronic ankle instability. Foot Ankle Clin. 2006;11:597–605. 10. Pagenstert GI, Hintermann B, Knupp M. Operative management of chronic ankle instability: plantaris graft. Foot Ankle Clin. 2006;11: 567–583. 11. Chrisman OD, Snook GA. Reconstruction of lateral ligament tears of the ankle. An experimental study and clinical evaluation of seven patients treated by a new modification of the Elmslie procedure. J Bone Joint Surg Am. 1969;51:904–912. 12. Evans DL. Recurrent instability of the ankle; a method of surgical treatment. Proc R Soc Med. 1953;46:343–344. 13. Watson-Jones R. The classic: “Fractures and Joint Injuries” by Sir Reginald Watson-Jones, taken from “Fractures and Joint Injuries,” by R. Watson-Jones, Vol. II, 4th ed., Baltimore, Williams and Wilkins Company, 1955. Clin Orthop Relat Res. 1974;105:4–10. 14. Hennrikus WL, Mapes RC, Lyons PM, et al. Outcomes of the Chrisman-Snook and modified-Brostrom procedures for chronic lateral ankle instability. A prospective, randomized comparison. Am J Sports Med. 1996;24:400–404. 15. Krips R, Brandsson S, Swensson C, et al. Anatomical reconstruction and Evans tenodesis of the lateral ligaments of the ankle. Clinical and radiological findings after follow-up for 15 to 30 years. J Bone Joint Surg Br. 2002;84:232–236. 16. Bell SJ, Mologne TS, Sitler DF, et al. Twenty-six-year results after Brostrom procedure for chronic lateral ankle instability. Am J Sports Med. 2006;34:975–978. 17. Marx RG, Stump TJ, Jones EC, et al. Development and evaluation of an activity rating scale for disorders of the knee. Am J Sports Med. 2001;29:213–218. 18. Naal FD, Impellizzeri FM, Leunig M. Which is the best activity rating scale for patients undergoing total joint arthroplasty? Clin Orthop Relat Res. 2009;467:958–965.
6 | www.pedorthopaedics.com
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
19. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15:349–353. 20. Brostrom L. Sprained ankles. V. Treatment and prognosis in recent ligament ruptures. Acta Chir Scand. 1966;132:537–550. 21. Chen CY, Huang PJ, Kao KF, et al. Surgical reconstruction for chronic lateral instability of the ankle. Injury. 2004;35:809–813. 22. Giannini S, Buda R, Vannini F, et al. Arthroscopic autologous chondrocyte implantation in osteochondral lesions of the talus: surgical technique and results. Am J Sports Med. 2008;36:873–880. 23. Giannini S, Ruffilli A, Pagliazzi G, et al. Treatment algorithm for chronic lateral ankle instability. Muscles Ligaments Tendons J. 2014; 4:455–460. 24. Hu CY, Lee KB, Song EK, et al. Comparison of bone tunnel and suture anchor techniques in the modified Brostrom procedure for chronic lateral ankle instability. Am J Sports Med. 2013;41:1877–1884. 25. Buerer Y, Winkler M, Burn A, et al. Evaluation of a modified Brostrom-Gould procedure for treatment of chronic lateral ankle instability: a retrospective study with critical analysis of outcome scoring. Foot Ankle Surg. 2013;19:36–41. 26. Marsh JS, Daigneault JP, Polzhofer GK. Treatment of ankle instability in children and adolescents with a modified ChrismanSnook repair: a clinical and patient-based outcome study. J Pediatr Orthop. 2006;26:94–99. 27. Yang J Jr, Morscher MA, Weiner DS. Modified Chrisman-Snook repair for the treatment of chronic ankle ligamentous instability in children and adolescents. J Child Orthop. 2010;4:561–570. 28. Baumhauer JF, O’Brien T. Surgical considerations in the treatment of ankle instability. J Athl Train. 2002;37:458–462. 29. Sefton GK, George J, Fitton JM, et al. Reconstruction of the anterior talofibular ligament for the treatment of the unstable ankle. J Bone Joint Surg Br. 1979;61-B:352–354. 30. Good CJ, Jones MA, Lingstone BN. Reconstruction of the lateral ligament of the ankle. Injury. 1975;7:63–65. 31. Kocher MS, Smith JT, Iversen MD, et al. Reliability, validity, and responsiveness of a modified International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC) in children with knee disorders. Am J Sports Med. 2011;39:933–939. 32. Fabricant PD, Robles A, Downey-Zayas T, et al. Development and validation of a pediatric sports activity rating scale: the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS PediFABS). Am J Sports Med. 2013;41:2421–2429.
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
