Modern methods of treatment of chronic lateral instability of the ankle joint (literature review)

Purpose: to study the literature data and analyze the immediate and long-term results of various modern methods of surgical treatment of patients with chronic post-traumatic lateral instability of the ankle joint.

Objective: to determine whether any of the proposed methods of surgical treatment of this pathology is optimal for reconstruction of the anterolateral ligament complex; to classify and unify approaches to the treatment of patients with chronic lateral instability of the ankle joint.

Materials and methods: Surgical treatment of lateral ligament instability was first described in 1932 based on the work of W.E. Gallie (1913) in paralytic clubfoot. Since then, many configurations of the peroneal tendon have been presented in the literature, including methods that involve rerouting from the peroneus brevis muscle around the lateral malleolus, including those of R. Watson-Jones (1952), D.L. Evans (1953), O.D. Chrisman, and G.A. Snook (1969). The non-anatomical method involves stabilization by tenodesis using the peroneus brevis tendon. Initial scientific reports were quite promising, but studies comparing the methods with longer-term follow-up generally favor the anatomical method of ligament reconstruction. The most common fundamental technique of anatomical reconstruction of the lateral ligaments of the ankle joint is the operation of L. Brostrom (1966). Anatomical reconstruction gives good and excellent results of ankle joint stability in 85 % of patients who underwent the modified Brostrom operation. No study has shown the superiority of more complex methods over the classic Brostrom method. However, the main disadvantage of anatomical reconstruction remains its dependence on potentially weak local tissues. A review of the literature revealed that studies that compared the Chrisman-Snook operation with the modified Brostrom reconstruction generally confirm a favorable outcome of both operations. Some authors came to the conclusion that in the treatment of CNG, the Brostrom operation gives better results than the Chrisman-Snook operation, others, due to the lack of statistically significant data, did not come to a conclusion about which surgical method of reconstruction is a priority. At the present stage, further studies are being conducted to determine the most effective method of surgical treatment of CNG. In studies examining the results of the modified Brostrom procedure, excellent functional scores were achieved, in addition to a successful clinical and radiographic outcome with 100 % excellent and good results at two-year follow-up. M. Glazebrook et al. (2016) showed that the ligament reconstruction surgery can be performed percutaneously using a single fibular tunnel to reconstruct the “Y” configuration of the anterior talofibular and calcaneofibular ligaments. To determine the best location for drilling holes in the fibula, the group of authors developed a template using CT scanning. As a result of the operations, patients experienced significant improvement in postoperative functional scores and radiographic stability compared to other ligament reconstruction techniques. An attempt has been made to speed up the healing process by improving the repair of ankle ligaments using catgut and screw interference, called the TM internal fixation device (Arthrex, Naples, FL), which is currently being actively discussed by the global trauma community.

Results: a group of authors conducted a detailed review of domestic and foreign literature on this issue. Descriptions of inventions to author’s certificates and patents of the Republic of Belarus and other countries were studied. The review showed that various methods of anatomical and non-anatomical reconstruction of chronic instability of the ankle joint have been developed and clinically tested. Most modern effective methods that provide good clinical and functional treatment results are closely related to the need for specialized structures and instruments. Questions remain open about planning and choosing a method of surgical treatment for chronic lateral instability of the ankle joint depending on the stage of the pathology, the duration of the primary injury, the technique of surgery depending on the patient’s age, rehabilitation treatment depending on the type of surgery and the permissible periods of partial and full load on the limb.

Conclusion: in general, the literature analysis convinces us that chronic ankle instability remains a common problem after acute trauma in people with an active lifestyle. The effectiveness of anatomical (Brostrom operation) and non-anatomical (Chrisman-Snook operation) methods of ligament restoration in chronic ankle instability has not been sufficiently studied. Risk factors for pathological processes that negatively affect the results of surgical treatment of patients with this nosology continue to be studied both in the Republic of Belarus and abroad.

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