Ankle stabilisation procedures represent an established surgical option for patients suffering from chronic ankle instability (CAI) not responding to conservative treatment. In recent times we have witnessed the development of the arthroscopic approach to CAI, mirroring what already happened in the shoulder and knee joints, where original open stabilisation techniques have progressively been replaced by all arthroscopic procedures (fig 1) [1]. The arthroscopic visualization of the ankle ligamentous structures has permitted a novel insight of the posttraumatic consequences of ankle injuries, sustaining the description of new clinical entities and therapeutic strategies. The concept of microinstability associated to the isolated injury of the superior fascicle of the anterior talofibular ligament (fig 2) and the renewed interest in the clinical role of the medial ligamentous complex are clear examples of the impulse given by the arthroscopic approach to ankle instability [2,3].

Fig. 1: The arthroscopic repair of the lateral ankle ligamentous complex (right ankle, 30° scope in the antero-medial portal). ATFL: Anterior Talo Fibular Ligament. LM: Lateral Malleolus

Fig. 2: Arthroscopic evaution of the lateral ankle ligamentous complex (right ankle, 70° scope in the antero-medial portal). ATFL: Anterior Talo Fibular Ligament. LM: Lateral Malleolus. Ta: Talus. The red arrow shows an avulsion of the upper part of the ATFL. The blue arrows indicate the talar insertion of the ATFL

Like in any field of the medical practice, a solid scientific support is required to promote the use of new therapeutic strategies in the daily practice. For this purpose, the definition of proper outcome tools is of primary importance both for the researcher to produce relevant data and the clinician to critically appraise the increasing amount of literature dealing with ankle instability treatment.

It has long been recognised that the direct patient’s perspective on their experiences with treatment, through the use of the patient-reported outcome measures (PROMs), is the best evidence to evaluate the effectiveness of a clinical intervention. The PROMs are considered appropriate in assessing the therapeutic outcome if they are psychometrically sound, meaning that they have shown to be valid, reliable and responsive in the specific population affected by the disease of interest [4]. Said in more clinician-friendly terms any outcome scale produces information relevant to the daily practice at the extent to which it has been proven capable to measure the pathology it is purported to measure and the eventual modification in the patient’s state after the treatment.

With this premise in mind, Spennacchio et al recently systematically analysed 15 years of CAI surgery literature to furnish an updated overview of the evaluation modalities chosen by researchers, aiming to depict current criticalities worthy of further improvement [5]. The results of the review highlight that the PROM’s selection is not always concordant with the best available evidence. Only a minor part of the researchers selects outcome scales with proofs of validation in the specific CAI population, namely the Karlsson score, the Foot and Ankle Ability Measure (FAAM) and the Foot and Ankle Outcome Score (FAOS) [6,7]. The AOFAS ankle/hindfoot scale [8] resulted the most frequently reported outcome score across the 104 included studies. This clinician-based score, has never been evaluated for validity and reliability in the assessment of ankle instability. The little emphasis on joint stability symptoms, makes it possible to rate the maximum score even in the event of a postoperative persistent subjective feeling of instability [9]. AOFAS outcome data may therefore fail to describe the clinical state of the CAI patient suggesting greater postoperative success than justified, which might contribute to promote inappropriate clinical practices. However, the historical unsupported common use of the scale, seems to represent a strong evidence since recent consensus statements keep on recommending its use to evaluate the results of CAI surgical treatment [10].

Another critical point highlighted by the review relates to the preoperative diagnostic criteria leading to an ankle stabilisation procedure. Researchers define ankle instability in a varied manner, using heterogeneous combinations of patient’s history, subjective symptoms, physical examination signs and imaging investigations. It appears that the common point across the reports is the stabilisation procedure itself rather than the treated disease, with subsequent negative impact on the external validity of the reported findings and a reliable comparison across studies. The need for a standardized patient’s selection is particularly topical in the light of the recent advances in the ankle instability field. An agreed definition of the emerging diagnostic hypothesis, such as the mentioned microinstability, is the first desirable step to produce the evidence required to support their clinical relevance.

In an attempt to increase the quality of the research on ankle instability the International Ankle Consortium proposed in 2014 some criteria to define a more homogeneous cohorts of patients to be enrolled in CAI clinical trials [11]. As a matter of fact, the initiative has so far been unreasonably ignored by most researchers dealing with ankle instability.

As recently reiterated by the experts we are in the middle of an ankle arthroscopic wave characterised by a renewed interest on ankle stabilisation procedures with the exciting potential to increase the quality of the clinical practice [12]. For this to become real it is of utmost importance that the scientific community dedicate future efforts to further standardize the selection of CAI patients in the research setting and promote the use of appropriate evaluation modalities for the proposed therapeutic strategies.

These are essential steps to improve the evidence necessary to recognize the real advances and keep on providing our patients suffering from ankle instability with the best possible practice.

Although the Speciality Days had to be rescheduled because of the Corona crisis, ESSKA-AFAS still provided a closed members meeting on 8 September 2021. We chose to combine our virtual ESSKA-AFAS members meeting with a scientific meeting for AFAS members. The scientific meeting focused on Lisfranc injuries.

In this article we will give a summary of the important take home messages from the session on Lisfranc injuries in the athlete. The whole session is, as all our webinars and instructional videos and lectures, will soon be accessible on the ESSKA Academy.

Regarding Lisfranc injuries, the session began with a review of important aspects of the Anatomy and Biomechanics by Dr. Akos Kynsburg (Austria). It’s always important to understand that the Lisfranc joint lies on the junction of the longitudinal and transverse arches of the foot, resulting in an intrinsic stability, as the traditional roman arches had. Another important feature is that tarsalmetatarsal (TMT) mobility is very different: medial column has less than 3º of motion, while joints located on the lateral column (TMT4-5) have around 10º of motion. This design allows the absorption function of the lateral column and the support and power function of the medial one, thus in terms of function and diagnosis, Lisfranc joint is one line with two functional halves.

The session was then followed by a very current issue – the use of Weight-bearing CT (WBCT) scans in Lisfranc injuries, by Prof. Gino Kerkhoffs (Netherlands). This exam is very useful, particularly in subtle injuries, where diagnosis of instability may be a challenge. Current studies show that comparison of WBCT 3D measurements, namely coronal volume difference between feet, is the best indicator for Lisfranc instability.

Next, Prof. Markus Walther (Germany), shed a light on an ongoing controversy – whether to fix or fuse Lisfranc injuries in the athlete. In order to treat such a wide spectrum of injuries, first it’s necessary to define what is the current injury at stake (Fig. 1).

When cartilage injury is significant, primary fusion is recommended, but no consensus exists in the remaining fracture-dislocations. Although some evidence points to better postural control and peak pressure after fusion, both treatments have similar outcomes (excluding planned hardware removal as a complication). Thus, choosing which technique you use, is a matter of what complication you rather deal – post-traumatic arthritis versus non-union. When you consider the athletic population into this discussion, arthrodesis may provide more stability/less pain, but specific activity must be considered, since dancers or athletes demanding flexibility from the midfoot may be best served with internal fixation.

Dr. Andrea Veljkovic (Canada) presented her approach on subtle Lisfranc injuries. Determining instability is paramount, since the treatment algorithm proposed by the Nunley classification is dated. Although WBCT is probably the most adequate exam, it isn’t widely available. WB x-rays are usually the first imaging approach, the issue is that absence of widening doesn’t prove absence of Lisfranc injury, and diastasis can be even less due to dorsal displacement of the base of M2. MR is useful in equivocal cases, with sensitivity of 94% and a positive predictive value of 94% for instability. Regarding treatment, new techniques of flexible fixation with Tightrope and other options such as the internal brace, and alternative configurations with and extra limb “over the top of the C1-C2 joint” were presented.

The session finished with Dr. Daniel Guss’ (USA) talk about Lisfranc instability in athletes. After presenting his initial workup, he presented his treatment algorithm (Fig. 2) that considers three main topics: energy, presence of fracture and chronicity.

After these very interesting lectures, discussion was rather interactive, from which we highlight some ideas:

• Flexible fixation does not shorten the non weightbearing time – ligamentous injuries still need time to heal.
• Fixation with ransarticular screws is inferior to plates - not only the screws damage the articular cartilage, but also reduction quality is inferior.
• Percutaneous fixation can be considered in fractures under one week of evolution, maintaining a low threshold to open reduction if anantomic reduction is in question.

If you missed the scientific meeting or would like to watch it again, the content will soon be available on the ESSKA Academy.

Daniël Haverkamp
ESSKA-AFAS Chairman

The next AFAS members' meeting will be an Online Meeting exclusive to AFAS members.

This meeting will focus on the topic "Lis Franc injuries" and will feature a 90-minute high level scientific programme followed by a members' meeting.

Lisfranc injuries of the midfoot have become increasingly recognized in the athletic population. As we know more about this topic we have to realize that there is still much more to be learned. In this speciality webinar we will focus on all aspects of Lisfranc injuries, from anatomy and biomechanics to diagnose, treatment and outcome. All with the focus on injuries in the athlete.

To view the preliminary programme for this meeting click below.

Would you like to join this meeting but are not an AFAS member yet? No problem, you can join AFAS today and still have time to register for the meeting!

Following the rescheduling of the ESSKA Speciality Days 2021 to November 2023, we are delighted to announce a series of four online Section Meetings organised exclusively for Section members.

A chance to get back together, enjoy some top-quality specialised science and hear the latest news from the Section leadership.

Each Section Speciality Meeting will focus on a specific topic and will feature a 90-minute high level scientific programme followed by a Members' meeting.

Save the date and keep an eye out for more information!

Not yet an ESSKA member or a Section Member? No problem - you can still join today!

Meta-analyses following Achilles tendon rupture have shown little difference in patient reported outcome between operative and non-operative treatment although rates of re-rupture tend to be lower with operative treatment but this method has higher rates of other complications. Kristoffer Barfod reminded us that non-operative management is difficult, requiring early intervention following rupture, correct immobilization and the careful selection of suitable patients. The latest research cast doubt on the outcome benefits of accelerated rehabilitation.

Lukas Weisskopf explained the importance of restoring the correct anatomy (especially the rotation and the soleus portion) and length of the Achilles tendon to optimise the most important functional outcome in athletes. Risk factors for functional relevant (re-rupture, elongation, deep infection) and non-relevant (wound healing disorders, superficial infection, sural nerve pathology) complications need to be assessed properly with any reconstruction techniques.

Elite athletes have the benefit of access to daily physiotherapy and James Calder recommends early range of motion exercises from full plantar flexion to neutral to avoid tethering and Compex sessions together with Occlusion training later in the rehabilitation programme.

The speakers used between 6-10 weeks in protective cast and brace following rupture.

The final speakers Hélder Pereira, Jorge Batista and Hajo Thermann, discussed what to do when patients present late or with problems such as elongation and re-rupture. Endoscopic Flexor Hallucis Longus transfer or free hamstring transfer techniques are technically demanding but both give good results minimising wound complications. FHL transfer has the advantage of bringing the vascular muscle belly to the site of rupture and subsequent remodelling.

This webinar attracted over 1000 registrations and attendees connected from more than 100 countries. To view this webinar recording, please visit the ESSKA Academy. If you cannot access the ESSKA Academy yet, you simply need to register once, for FREE, as an ESSKA Academy user here. You will then have instant access to regularly updated content.

Without doubt this is an area requiring much development and research. Attendees at the Speciality Day in Poland later this year will experience an enthusiastic head-to-head debate and have the chance to pose questions to the proponents of these techniques. This will be a great session!

Mike Carmont and Stéphane Guillo
ESSKA-AFAS Board Members