Evolution in Surgical Management of Ankle Instability in Athletes

Brian C. Lau, MD; Alexej Barg, MD; C. Thomas Haytmanek, MD; Kirk McCullough, MD; Annunziato Amendola, MD

J Am Acad Orthop Surg. 2021;29(1):e5-e13.

Summary

Ankle instability in athletes has evolved with much more detailed evaluation, better appreciation of associated findings and pathology, and management of medial and syndesmotic instability when present (Table 1). Ankle arthroscopy has allowed more comprehensive diagnosis and treatment in both the acute and chronic setting of ankle instability. With the goals of optimal return to play and better outcomes, surgical options using all-arthroscopic or synthetic-augmentation and expedited rehabilitation protocols continue to evolve.

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Lau or an immediate family member has received research or institutional support from Arthrex and Wright Medical Technology and serves as a board member, owner, officer, or committee member of American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America. Barg or an immediate family member has received Honoraria from Medartis. Haytmanek or an immediate family member serves as a paid consultant to Arthrex and has received education support from Wright Medical. McCullough or an immediate family member serves as a paid consultant to Athrex, Stryker, and Celularity. Amendola or an immediate family member has received IP royalties from Arthrex, arthrosurface, Smith & Nephew; serves as a paid consultant to Arthrex; serves as an unpaid consultant to bone solutions, extremity development, First Ray, Lima, and rubber city bracing; has stock or stock options held in First Ray; and serves as a board member, owner, officer, or committee member of American Orthopaedic Society for Sports Medicine.

Table 1. Summary of Treatment Considerations
Concept	Considerations
Hindfoot alignment	Assessing alignment during physical examination and with Coleman block testing is useful. Evaluate varus alignment as risk factor for injury and failure of repair
Medial ankle instability	Deltoid injury is common with lateral ligament sprain. Carefully evaluate on physical examination and arthroscopically.
Ankle arthroscopy	Use during operation to aid in evaluation of concomitant injuries.
Suture anchors	Using suture anchors over transosseous tunnels may decrease surgical time and be more reproducible. Suture anchors increases costs.
Suture tape augmentation	Biomechanical testing demonstrates greater strength. Early clinical data are promising. May be beneficial in at-risk populations (eg, generalized laxity or revision cases)
All-arthroscopic stabilization	Comparable biomechanical, clinical, and radiographic outcomes. Risk of nerve injury is 2.1%. May improve pain in the early postoperative phase. May facilitate earlier rehab and return to daily activities.
Early weight bearing	Consensus statements recommend short periods of immobilization (2 wk) after operation. Some studies show that immediate weight-bearing is also safe. Early weight-bearing may expedite return to play.

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Evolution in Surgical Management of Ankle Instability in Athletes

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