This paper reviews the causes of chronic instability after total hip arthroplasty (THA). The overall reported incidence varies from 0.5% to 9.5%. At 2% to 6%, the incidence following primary THA is higher with a posterior approach than with an anterior approach (0.5% to 3%). The incidence is reported to be as high as 22% after revision THA and 50% after extensile triradiate approach for pelvic discontinuity. Inadequate soft tissue lengthening, damaged abductors and nonunion of trochanteric osteotomy are known to predispose patients to chronic instability after THA. Elderly women are particularly susceptible. Poor patient compliance is also a cause. Surgical technique is also a factor. The lateral decubitus position often causes flattening of the lumbar lordosis, leading to potential cup retroversion. Over 90% of all dislocations are posterior, and disruption of external rotators and capsular damage should be repaired if possible. The optimal implant position appears to be 40° TO 45° of abduction, 15° to 20° of femoral anteversion, and 20° to 30° of cup flexion. Elevation of the hip centre weakens abductor pull, causing instability. Because a reduced femoral offset causes potential instability, this should be measured preoperatively to make sure that the stem can provide adequate offset. It may be necessary to add a thicker liner to increase the offset. Prosthetic factors which play a role in chronic instability include the use of smaller femoral heads, thick necked stems and heads with skirts. A larger femoral head increases stability simply by increasing the radian about the hip centre, increasing the potential range of motion. Extended posterior wall-adds improve the range of motion, and consequently the stability. However, there are fears that their use may increase the incidence of impingement and/or lead to increased wear. Skirted femoral heads impinge on the liner, limiting movement, and their use should be avoided in most cases of instability. Femoral stem offset relates to the neck shaft angle and the effective hip centre/shaft axis length or offset. It is easier to increase offset with lower neck shaft angle than to lengthen the leg. Because a bell curve is used in the design of femoral stems, many prosthetic systems lack adequate offset, especially when larger stems (48 mm to 52 mm) are used. In earlier prosthetic designs, bulk was added to the necks to eliminate stem breakage. In certain stems, the way in which dimensions were scaled meant the neck dimensions of larger prostheses were disproportionately big. We stopped using Depuy Stability stems sizes 16 mm and 18 mm because of this. Thornberry et al have shown that a circulotrapezoidal neck design is the best shape and leads to the least impingement. They have also shown that increasing the width of the chamfer of the acetabular liner rim improves the range of motion. In treating early instability (occurring less than 30 days postoperatively) most authors recommend bracing for six to eight weeks and warning patients severely about the long-term potential of redislocation. In cases of chronic instability (occurring more than 30 days postoperatively) all potential problems must be explored: these include soft tissue laxity, cup retroversion, inadequate offset, surgical approach, etc. In managing multiple dislocation, the use of extended immobilisation is less desirable although patients who have undergone revision have been subjected to a great deal of soft tissue dissection and potentially should be braced for up to 12 months. If the cause is correctable-malpositioning, soft tissue laxity or bony impingement – treatment is likely to be successful in 85% of cases. However, if the implants are in good position, the ‘bloodless revision’ (Fehring) has less than 50% chance of succeeding. The implication is that an extended posterior wall liner, longer modular femoral head, and soft tissue reconstruction are not going to work in the majority of cases. Designed by Noiles, the J& J SROM constrained acetabular liner uses a polyethylene capture mechanism that is secured by two additional screws. The pullout strength of this device is 1 350 N but torque required (lever-out strength) diminishes to 17.3 N.m for a 28-mm head. With a 32 mm head, 105° of flexion was obtained (while the normal hip needs up to 113° for usual flexion). Following up 21 patients with this implant for over two years, Anderson et al found redislocation in 29%. The only causative factor identified was an abduction angle of more than 70°. However, there were no cases of implant loosening of this device. Prevention of loosening was one of the design goals in using a ‘softer’ locking mechanism. Dislodgement of the liner requires immediate re-operation. The Osteonics constrained liner cup has a dual socket. The inner socket has a polished chrome surface manufactured fit to the outer socket. It fits a 22 mm or 28 mm head, and has a locking ring identical to the bipolar implant that holds the head in place. The implant can be snap-fitted into a 52-mm or larger Osteonics cup. This liner can also be cemented into another metal-backed liner. Goetz et al evaluated 56 cases, in 10 of which this implant had been cemented and in 46 lock-fitted in appropriately matched metal shells. In one case, the cemented constrained liner had separated from the metal shell. None of the constrained liners had separated from the metal shells, but one shell had loosened. There are many similar constrained acetabular liners. The choice is between a ‘locked’ liner that can never separate and a ‘softer’ lock that may protect fixation of the cup

Between 1997 and 2005, 10 patients with chronic instability of the elbow underwent surgical stabilisation. There were 5 men and 6 women with a mean age of 41 years (16 to 58). All patients had initially dislocated the elbow at a mean of 5.6 years (6 months to 25 years) prior to surgical reconstruction. There were 8 chronic lateral and 2 medial reconstructions performed. The presenting symptoms, findings on clinical examination and methods of surgical reconstruction are defined. Two patients underwent reconstruction using an artificial ligament (Corin) as they had evidence of ligamentous laxity and at the time of assessment all the other patients had been treated using autografts. At a mean follow up of 3 years (1 to 6 years) all patients except one reported no symptoms of pain or instability and had been able to return to their normal work and social activity. The one patient with persisting elbow instability had Ehlers-Danlos syndrome and underwent a second revision procedure again using an artificial ligament (Corin). This review represents our surgical experience and functional outcomes with this rare form of ligamentous elbow injury

Purpose: Dislocation of total hip arthoplasties is a sad reality. The incidence of this complication is estimated from 0.6 to 8%. Dislocation can be a single event that never recurs, but half of all dislocations will reoccur again. We analysed outcome after treating chronically unstable total hip arthroplasties using a double-mobility cup. Material and methods: Between 1990 and 2000, we treated 42 cases of recurrent dislocation of total hip arthroplasties. Five were immediate, 33 early, and four late; five dislocations on the average. The prosthesis was implanted via the posterolateral approach for 36 patients. Thirteen patients treated in our unit had already had surgical treatment for chronic instability: 1 trochanteoplasty, 8 bone blocks, 5 restraining cups. A standing AP view of the pelvis was obtained in all patients before surgery to analyse shortening (gluteus medius insufficiency), cup tilt and anteversion, and stem lateralisation. Likewise a CT scan was performed systematically to analyse stem and cup anteversion. No position anomaly was found in 17 patients; at least one anomaly was found in the others. All patients were reoperated via the posterolateral approach. A double-mobility cup was implanted systematically without changing the stem. Results: Among the 42 patients, we had two with recurrent dislocation, one in a neurologic patient and one in a patient with major anomalies in the position of the femoral component that was not changed. The incidence of recurrent dislocation was thus 4.75%. Discussion: The therapeutic method used here can be compared with other solutions (trochanteroplasty, anti-dislocation crescent, antidislocation bone block, bipolar replacement). The double-mobility cup is particularly interesting for high-risk patients: neck fracture, tumour surgery, neurological disease, antecedent non-prosthetic surgery (dearthrodesis prosthesis). We advocate revision surgery after three dislocations. Conclusion: The double-mobility cup appears to be a valid therapeutic option, both for the treatment and prevention of chronic instability of total hip arthroplasty

Knees of patients with chronic anterior cruciate ligament instability and who were awaiting surgery were examined with respect to increasing co-morbidity following diagnosis and subsequently during surgical reconstruction. 141 patients were included in this study. All had undergone initial arthroscopic evaluation of their unstable knees following diagnosis and subsequently a further arthroscopy was performed at a later stage during hamstring anterior cruciate ligament reconstruction. All injuries to the menisci and articular cartilage were recorded using a standardised evaluation form. The Lysholm and Tegner scores were obtained as well as knee stability using the KT-2000 arthrometer. Successive deterioration in the Lysholm and Tegner scores and the arthrometric side to side difference was noted with time since injury. Initial arthroscopic examination of the knee revealed that 66 patients (46%) had at least one meniscal injury necessitating treatment whilst 67 (47.5%) had at least one chondral lesion on the femoral condyles. 22 patients (15.6%) presented with chondral lesions of the articular surface of the patella. During definitive ACL reconstruction when a second arthroscopy was performed, it was noted that 111 patients (78.7%) had meniscal pathology, 102 patients (72.34%) had intraarticular chondral lesions and the patella was affected in 41 cases (29%). The delay between initial arthroscopy and stabilization was 16 +/− 5.2 months (range 7–19 months). The difference in the arthroscopic findings between the first and second arthroscopic inspections in terms of meniscal and chondral lesions was statistically significant. Knee instability due to chronic ACL deficiency poses a serious threat to the menisci and the articular cartilage of the affected knee. The severity of these lesions increases with time since injury. ACL reconstruction should be undertaken as soon as possible in those individuals with uncompensated anterior cruciate ligament instability

Introduction. Chronic ankle instability is a common condition that can be effectively treated with arthroscopic lateral ankle ligament reconstruction to restore ankle stability and function. The aim of this study was to assess the functional outcomes of arthroscopic lateral ligament reconstruction using the MOXFQ, VAS, and EQ5D patient-reported outcome measures (PROMs). Methods. This prospective series included 38 patients who underwent arthroscopic lateral ligament reconstruction for chronic ankle instability between December 2019 and April 2022. All patients completed the MOXFQ, VAS, and EQ5D PROMs preoperatively, as well as at6, and 12 months postoperatively. The MOXFQ is a disease-specific PROM that assesses foot and ankle function, while the VAS measures pain and the EQ5D evaluates health-related quality of life. Results. At the 12-month follow-up, the mean MOXFQ Index score had improved significantly from 53.3 ± 23.1 preoperatively to 16.0 ±21.1 (p < 0.001). Similarly, the mean VAS score had improved from 36.2 ± 22.4 preoperatively to 14.7 ± 15.0 (p < 0.001), and the meanEQ5D score had improved from 0.55 ± 0.26 preoperatively to 0.87 ± 0.12 (p < 0.001). No major complications were observed. Conclusion. Arthroscopic lateral ligament reconstruction is an effective treatment for chronic ankle instability, with significant improvements in clinical and health-related quality of life outcomes

Purpose: Post-traumatic instability of the elbow is defined as a subluxation of the humeroulnar joint at least three weeks after trauma. Treatment is based on restitution of the three elements essential for stability: the coronoid process, the height of the head of the radius, repair of the lateral ligaments. The purpose of this study was to analyse treatment modalities for these unstable elbows and assess mid-term results.

Material and methods: This consecutive series included all patients who underwent surgery between 1992 and 2000. There were 22 patients (twelve men and ten women, mean age, 46 years, age range 26–74 years). The left elbow was involved in 16 cases (two dominant) and the right elbow in six cases (six dominant). The initial trauma was isolated dislocation in six patients, dislocation with fracture of the coronoid process and the head of the radius in nine, trans-olecranon fracture-dislocation in seven. Mean time from trauma to revision for instability was four months. A dynamic external fixator was used for stabilisation in all cases, with or without restoration of the height of the radius with a radial head prosthesis (n=12), and reconstruction of the coronoid process (n=7). Reinsertion of the lateral ligaments was necessary in 17 patients.

Results: Mean follow-up was 33 months. Six patients required a second procedure for transposition of the ulnar nerve in three and arthrolysis of the elbow joint in three. There was one failure requiring total elbow arthroplasty less than one year after revision. At last follow-up, outcome according to the Mayo Clinic classification was excellent in ten patients, good in five, fair in one, and poor in five (four trans-olecranon fracture-dislocations). Twenty patients had a stable elbow. Mean flexion-extension was 113° with a 19° mean extension deficit. At last follow-up, six patients had radiographic signs of osteoarthritis.

Discussion and conclusion: The results were directly correlated with the nature of the initial trauma and the quality of the restoration of he stabilising elements. The poorest results were observed after trans-olecranon fracture-dislocation, which led to osteoarthritic degradation in three out of four cases. In our experience, treatment of sequelae of elbow dislocation, or the terrible triade, can give satisfactory results with an appropriate treatment strategy.

Aims. This cross-sectional study aimed to investigate the in vivo ankle kinetic alterations in patients with concomitant chronic ankle instability (CAI) and osteochondral lesion of the talus (OLT), which may offer opportunities for clinician intervention in treatment and rehabilitation. Methods. A total of 16 subjects with CAI (eight without OLT and eight with OLT) and eight healthy subjects underwent gait analysis in a stair descent setting. Inverse dynamic analysis was applied to ground reaction forces and marker trajectories using the AnyBody Modeling System. One-dimensional statistical parametric mapping was performed to compare ankle joint reaction force and joint moment curve among groups. Results. The patients with OLT showed significantly increased dorsiflexion moment in the ankle joint compared with healthy subjects during 38.2% to 40.9% of the gait cycle, and increased eversion moment in the ankle joint compared with patients without OLT during 25.5% to 27.6% of the gait cycle. Compared with healthy subjects, the patients with OLT showed increased anterior force during 42% to 43% of the gait cycle, and maximal medial force (p = 0.005, ηp2 = 0.399). Conclusion. The patients with concomitant CAI and OLT exhibit increased dorsiflexion and eversion moment, as well as increased anterior and medial ankle joint reaction force during stair descent, compared with patients with CAI but without OLT and healthy subjects, respectively. Thus, a rehabilitative regimen targeting excessive ankle dorsiflexion and eversion moment may help to reduce ankle joint loading. Cite this article: Bone Joint Res 2024;13(12):716–724

Introduction and Objectives: The aim of this study is to evaluate the results of the technique described by Ahlgren and Larsson in 1989, presenting our experience with 7 patients.

Materials and Methods: A retrospective study was conducted on the clinical records of 7 adolescents treated in our center beginning in 1991 using the technique described by Ahlgren and Larsson. There were 3 males and 4 females, ranging in age from 13 to 16.5 years (average: 14 years 10 months). All subjects had a history of repeated ankle sprains for 2 to 5 years before surgery. In all cases there was painful instability of the ankle which significantly limited physical activity. In 4 cases, symptoms were present even when walking on level ground. On clinical examination, 3 cases showed significant instability under varus stress, 3 others had moderate instability, and one case had mild instability. Surgical technique was similar in all cases and involved creating a periosteal flap with a distal anterior base, including the fibulotalar and fibulocalcaneal ligaments, which was sutured with tension to the fibula. In 3 cases, this was done with the help of Mitek metal hooks. In 5 of 7 cases, an ossicle of the fibular malleolus visible on the radiographs was removed. Duration of surgery ranged from 30 to 60 minutes, with a mean of 40 minutes. Postoperative immobilisation consisted of a plaster cast used for an average of 45 days, after which time patients progressively returned to normal physical activities. Patients were advised to use an ankle brace. Average follow-up time was 35 months, with a range of 13 to 72 months.

Results: In 5 patients, a subjective improvement in ankle stability was found on examination. Only in one case was there a significant reduction in radiographic instability when the tibiotalar joint was moved from 20° to 8°. One patient developed a superficial infection of the surgical wound which resolved with antibiotic treatment. Two patients suffered sprains within the first year after intervention, but there were no further sprains, and the injuries did not seem to affect the final outcome. However, the outcome of one of these was considered to be only fair due to occasional mild pain which did not limit physical activity. Two cases had poor outcomes due to frequent pain which limited physical activity postoperatively for 2 and 6 years, respectively. However, neither patient had repeat sprains during this period. The remaining 4 cases were considered to have had good results, as the patients were totally asymptomatic and without any limitation of physical activity.

Discussion and Conclusions: This simple, non-aggressive method is an attractive option for use in adolescents. We therefore conclude that more studies are needed to validate its effectiveness.

Hypotheses: The modified Brostrom procedure is an anatomic reconstruction of the lateral ankle ligaments. The aim of this retrospective study was to determine the clinical outcome after surgical repair of the lateral ankle ligaments using suture anchors as part of the modified Brostrom procedure in the treatment of chronic anterolateral ankle instability.

Methods: All patients were evaluated postoperatively by physical examinations and stress radiographs using Telos® equipment. Additional postoperative assessment consisted of a questionnaire, inversion and eversion isokinetic strength measurements and Sachs hop test to assess ankle confidence.

Results: Over a 3 year period, 27 young, athletic patients (mean age at operation 22 years) underwent anatomical reconstruction by the senior author. At a mean follow-up of 14 months (range 3–36 months), 25 (91%) reported a good or excellent functional outcome as assessed by the Karlsson and Peterson ankle function scoring scale. Twenty-five patients had no evidence of instability on physical examination or on stress radiographs. One patient required revision. One patient developed a superficial wound infection, which responded to oral antibiotics. Twenty five patients were able to jump 97% of the hop distance of the non operated ankle.

Conclusions: Reconstruction of the lateral ankle ligaments using the modified Brostrom procedure with suture anchors results in a good or excellent outcome in the majority of patients engaged in physically demanding sports.

Aims: To evaluate the role of Blatt’s capsulodesis and scapholunate ligament repair in patients with chronic scapholunate instability. Methods: Nineteen (15 males, 4 females) patients with chronic scapholunate instability underwent surgical repair and dorsal capsulodesis. At a mean follow-up of 28 months, all patients were assessed to identify any improvement in analogue pain scores, grip strength, range of movement of wrist and overall result of surgery. Results: Pre-operative arthroscopic findings revealed a scapholunate gap of > 2mm and ease at visualising the capitate by passing the scope through the scapholunate interval confirming the diagnosis. Surgery consisted of repair of torn ligament and supplementary dorsal capsulodesis (Blatt’s technique). 12 patients (63%) had returned to normal working activities at pre-injury level. There was a marked improvement in level of pain (mean pain level= 8.7 pre-operative vs. 2.3 postoperative, p=0.003). Seventeen patients (89.5%) would recommend this operation to others with similar problems. Only one patient (5%) rated the results as worse off following surgical intervention. Statistically significant pain improvement and grip strength were noted. ROM of wrist did not improve in most patients. Conclusion: Treatment of the chronic scapholunate instability remains contentious. It is suggested early surgical intervention will benefit majority of the patients. Our result concluded that Blatt’s capsulodesis has a role in chronic scapholunate instability

Background. Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency. Methods. We performed a retrospective study of all consecutive patients who underwent modified Brostrom repair for symptomatic recurrent instability of the ankle. All patients underwent a MRI scan prior to surgery. Arthroscopy was performed in all the patients before lateral ligament reconstruction. Seventy seven patients with 78 ankles were included in the study. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Data was obtained from clinical and radiological records. Arthroscopic findings were recorded in detail during the surgery. Results. The mean age was 29.8 years (Range 18.2–58 yrs). There were 44 females and 34 males in the study. The incidence of chondral lesions were 11.5% (9 out of 78 ankles). The commonest site for chondral defect was the anteromedial talar dome. The incidence of anterolateral impingement which required arthroscopic debridement was 48.7 %(38 ankles). A further 10 ankles revealed non-specific synovitis and scarring which was debrided. The sensitivity and specificity of the MRI scans in the assessment of chondral lesions is 91% and 100%. Conclusion. The incidence of chondral lesions in chronic ankle instability is lower than previously published literature. However, soft tissue impingement lesions have a much higher incidence and require debridement. Arthroscopic examination and debridement of impingement prior to lateral ligament reconstruction of the ankle is quintessential in the management of chronic anterolateral instability

Introduction: Ankle inversion injuries are common, with an incidence of 1 per day per 10,000 of the population. Chronic instability is a frequent sequela, and has been estimated to occur after approximately 10 to 20% patients, regardless of the type of initial treatment. Magnetic Resonance Imaging (MRI) has become a routine diagnostic tool in investigating knee injuries, but little has been published concerning ankle injuries and ankle instability. Aim: To compare the efficacy of conventional magnetic resonance (MR) imaging and stress radiography in the detection of lateral collateral ligament abnormalities in patients with chronic ankle instability. Materials and Methods: All patients presenting to the senior author’s OPD with clinical impression of ankle instability were investigated prospectively using MRI and stress x-rays (Telos). These films were officially reported and then, these reports were subsequently reviewed post-anatomical reconstruction. Results: Over a two-year period, 18 patients underwent anatomical reconstruction using the modified Brostrom technique. MRI identified a tear of the anterior talofibular (AFT) ligament in 12 (66%) patients, and the calcaneofibular (CF) ligament was torn in 9 (50%) patients. Stress radiography identified instability of 14 of the 18 (77%) patients. Stress radiography identified instability of 14 of the 18 (77%) patients. Surgical exploration revealed either attenuation or rupture of either the AFT and/or CF ligaments in all 18 patients. MRI demonstrated concomitant injuries to the ankle and subtalar joints, including peroneal tenosynovitis (76%), anterolateral impingement syndrome (66%) and attenuated peroneal retinaculum (55%). Conclusion: Ankle instability may be more reliably demonstrated using stress x-rays than MRI: however, lowfield MRI is a very useful diagnostic tool in the study of concomitant ankle injuries and we would suggest that both modalities be considered, especially if surgical intervention is anticipated

Background. Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency. Methods. We performed a retrospective study of all consecutive patients who underwent modified Brostrom repair for symptomatic recurrent instability of the ankle. All patients underwent a MRI scan prior to surgery. Arthroscopy was performed in all the patients before lateral ligament reconstruction. Seventy seven patients with 78 ankles were included in the study. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Data was obtained from clinical and radiological records. Arthroscopic findings were recorded in detail during the surgery. Results. The mean age was 29.8 years (Range 18.2 – 58 yrs). There were 44 females and 34 males in the study. The incidence of chondral lesions were 11.5% (9 out of 78 ankles). The commonest site for chondral defect was the anteromedial talar dome. The incidence of anterolateral impingement which required arthroscopic debridement was 48.7% (38 ankles). A further 10 ankles revealed non-specific synovitis and scarring which was debrided. The sensitivity and specificity of the MRI scans in the assessment of chondral lesions is 91% and 100%. Conclusion. The incidence of chondral lesions in chronic ankle instability is lower than previously published literature. However, soft tissue impingement lesions have a much higher incidence and require debridement. Arthroscopic examination and debridement of impingement prior to lateral ligament reconstruction of the ankle is quintessential in the management of chronic anterolateral instability

INTRODUCTION: The authors present the results of a surgical technique for lateral ankle chronic instability, derived from Castaing and Duquennoy procedures. It uses a half peroneus brevis with a tightening of the antero- lateral capsule. A Plasty with the extensorum digitorum brevis was used in the event of associated subtalar instability. MATERIAL AND METHODS: Between 2001 and 2005, 38 cases of ligamentoplasties have been performed for chronic instability of the ankle. 32 (25 men and 7 women) of them have been reviewed with a mean delay of 26 months (extremes of 10 months to 5 years). They were middle-aged of 28,5 years. All the patients have been reviewed with stress X-Ray in varus of the both ankles (measure of tibio talar angle, arthritis) and had a strength measure in eversion by the same examiner. The functional evaluation was performed with Molander and Olerud ankle score. RESULTS: There were 20% of complications, especially cutaneous cicatrisation problems and algodystrophy. After surgery, no patient had instability; only one, had apprehension of the ankle. 90 % retrieved the same sport with the same level. No body changed of job. 3 patients were disappointed because of pain in sports and stiffness. At revision, the functional score was 90 against 59 at the pre operative time. The difference of strength in eversion between the two ankles was about 7%. Laxity had a good correction seeing the average tibio talar angle between the both ankle is 0,5°. DISCUSSION: The results of this procedure show a distinct improvement of stability, radiological laxity and functional activity. The arthrotomy performed in Duquennoy procedure, is useful for diagnosis and treatment. It shows the cartilage and allows the removal of impingement and foreign bodies. A plasty that uses the single evertor deprives the ankle of a part of active and proprioceptive control. However, the patients didn’t feel a difference or a discomfort. The patients who had the surgery on the jump foot side had no significative difference of strength in eversion between the both ankles. CONCLUSION: This anatomical procedure gives 91% of satisfaction, for these active young people. The postoperative physiotherapy allows the complete recovery of activities from the sixth month after surgery

Introduction and purpose: Numerous surgical procedures have been developed for the treatment of chronic ankle instability, which can be broken down into two: tenodesis of the peroneus brevis and ligament capsuloplasty. We assess the indications for these procedures, discuss their advantages and disadvantages based on a comparative review, and describe an algorithm in the treatment of this pathology. Materials and methods: We reviewed 21 patients who underwent surgery from 1997 to 2001. In 10 of the patients the operation consisted of a Castaing II procedure with tenodesis of the peroneus brevis, and in 11 a Larsson procedure was performed as a ligament capsuloplasty. The ankle was evaluated using the AOFAS scale. Results: The age difference between the two groups, which was 40 for those undergoing the Castaing II procedure and 28 for the Larsson technique. The mean AOFAS score was 80% (min. 70%, max. 95%) for the Castaing II procedure and 86% (min. 71%, max. 97%) for the Larsson technique. Conclusions: The use of tenodesis with the peroneus brevis is indicated for severe ankle instability, failed anatomical repairs and in patients with connective tissue pathology. A capsuloplasty that attempts to reconstruct the lateral ligaments of the ankle as anatomically as possible is indicated for mild-to-moderate chronic instability in young patients

Purpose: Chronic ankle instability is generally related to lateral laxity of the tibiotalar joint. Stress x-rays may however be negative. Varus of the hindfoot is another possibility. In such cases, it would be logical to propose Dwyer valgus osteotomy of the calcaneum. The objective of this work was to review patients who underwent Dwyer osteotomy from 1992 to 2000. Material and methods: The series included fifteen patients, nine men and six women, who complained of chronic ankle instability with no evidence of laxity. All presented a varus hindfoot (mean 5°, range 3–10°). Thirteen patients practiced sports, including eight at the competition level. Sixty percent had experienced instability accidents during sports activities. Associated lesions were fissures of the fibular tendons (n=2), osteochondral lesion of the talar dome (n=1), Haglund disease (n=1) and stage II pes cavus (n=2). Lateral closed Dwyer osteotomy was performed in all cases, generally with fixed with two screws in a 2-hole 1/3 plate. Associated procedures were: lateral ligamentoplasty (n=1), osteotomy to raise M1 (n=2), regularisation of an osteochondral lesion of the talar dome (n=1), Zadek osteotomy (n=1) and anterior arthrolysis (n=1). The same surgeon reviewed the patients clinically and radiologically, independent of the operator. Results: Mean follow-up was 3.5 years (range 1–9, SD 2.5). There were no complications except one case of cutaneous necrosis in the patient who had simultaneous osteotomy and ligamentoplasty. Instability resolved in all patients. Ten patients experienced minor episodic pain (50% during sports activities). Eleven patients (70%) resumed their sports activities within eight months (3–36) and 33% at their former level. The mean Kitaoka score was 92 (85–100) and 80% of the patients were satisfied or very satisfied. Conclusion: Dwyer osteotomy provides quite satisfactory results for patients with chronic ankle instability without evidence of laxity and hindfoot varus. When a complementary ligamentoplasty appears to be necessary, it is preferable to wait for a second operation in order to avoid the risk of cutaneous necrosis

Aims: Hindfoot deformity in varus position is an aetiology of chronic ankle instability without laxity. In this condition, a Dwyer osteotomy has to be performed. Methods: Between 1992 and 2000, 15 patients have been operated on, with this technique. The mean varus deformity was of 5û (3û to 10û).13 patients had sporting activities, 8 of them in competition. Instability during sporting activity were present in 60% of cases. Associated lesions were reported in 6 cases. A Dwyer procedure using a 1/3 tube plate þxed with two screws were performed in all cases. Associated procedures were performed at the same time as such as a lateral ligamentoplasty or a þrst metatarsal osteotomy. All patients were reviewed clinically and radiologically using AOFAS score. Results: The mean follow-up was of 3.5 years (1 to 9 years). The only one complication reported was a skin necrosis, treated by a cutaneous ßap in a patient operated on with Dwyer and ligamentoplasty in the same procedure. No ankle instability was reported. Mild pain was reported in 10 patients and 50% of them only for sporting activities.11 patients returned to sporting activity and 33% of them at the same level. The mean Kita-oka score was of 92 (85 to 100). The patients were satisþed and very satisþed in 80 of cases. Conclusions: Dwyer lateral closing wedge calcaneal osteotomy is successful for the treatment of chronic ankle instability without laxity and with varus hindfoot deformity. When laxity is associated with varus deformity an operative procedure in two steps is necessary to avoid wound complication. Dwyer osteotomy has to be performed þrst

Aims

There remains a lack of consensus regarding the management of chronic anterior sternoclavicular joint (SCJ) instability. This study aimed to assess whether a standardized treatment algorithm (incorporating physiotherapy and surgery and based on the presence of trauma) could successfully guide management and reduce the number needing surgery.

Purpose of study: To evaluate the clinical outcome of operative intervention for chronic patellar instability for patients treated by a single paediatric orthopaedic surgeon over a 74-month period. Method: There were 11 patients (16 knees) with a mean age at operation of 11.9 years (5 to 17 years). Patients were treated with combined proximal and distal patellar realignment. Mean follow-up was 44.6 months (11–86 months). All patients were assessed post-operatively with satisfaction scores, the Trillat grading system and the Activity Scale for Kids (ASK). They were also questioned specifically for patellofemoral symptoms and examined for signs of mal-tracking. Results: Subjective patient rating of all procedures revealed 10 (62.5%) responses of excellent or very good, 4 (25%) good, 1 (6.25%) fair and 1 poor (6.25%). Formal Trillat grading revealed 9 (56.3%) excellent, 6 (37.5%) good, 1 (6.2%) fair and no poor outcomes. The mean ASK score was 82% (39–100%). All except one patient felt that they would choose to undergo the surgery again. There was one complication of a superficial wound infection. Conclusions: These results show improvement in symptoms and function as judged by Trillat grading and a majority of patients satisfied with the results of the procedure. We feel that the advantage of appropriate surgical intervention at a young age is not only the improvement in symptoms, but also that successful realignment of patellar tracking may reduce subsequent degenerative problems associated with chronic instability and allow better rehabilitation of the dynamic stabilisers of the patellofemoral joint

Introduction: Ankle sprains are among the most common injuries in sports and recreational activities. 10 to 40% of the acute ankle sprains lead to chronic ankle instability (CAI), which can be divided into its mechanical and its functional division. The clinical-orthopaedic diagnosis of mechanical ankle instability (MAI) has been well established, whereas the etiology of the functional ankle instability (FAI) is still not objectively allocatable. The aim of this study was to identify neuromuscular patterns in lower leg muscles to objectively describe the FAI. Methods: 15 patients suffering from unilateral CAI (mean age, 35.5 years) since 2.4 years (1–9 years) were examined. The patients were evaluated etiologically and clinically (VAS pain score, AOFAS Ankle Score, calf circumference, and SF-36). Electromyographic (EMG) measurements of surface EMG with determination of mean EMG frequency and intensity by wavelet transformation were taken synchronously with dynamic stabilometry measurements. Four lower leg muscles were detected: tibialis anterior (TA), gastrocnemius medialis (GM), soleus (SO), and peroneus longus (PL) muscle. 15 healthy subjects were tested identically. Results: Patients showed higher stability indices, higher VAS score, and lower AOFAS Ankle Score. The mean EMG frequency was significantly lower for the PL (pathologic leg, 138.3 Hz; normal leg, 158.3 Hz, p< 0.001). Lower mean EMG intensity was found in the pathologic PL and GM. The mean EMG frequency of the TA was lower in the patient group, its intensity higher. Discusssion and conclusion: Patients suffering CAI demonstrate weakened stability and impaired life quality. Neuromuscular patterns of the GM, PL and TA lead evidently to an objective etiology of the functional ankle instability. EMG patterns of four lower leg muscles indicate chronic changes in muscle morphology, such as degradation of type-II muscle fibres or modified velocity of motor unit action potentials. Accurate prevention and rehabilitation may compensate a MAI with a sufficient functional potential of lower leg muscles. This may also avoid operative treatment of MAI. The present study evidences the etiology of the FAI with objective parameters and indicates chronic changes in muscle morphology within CAI-Patients