Sung Hyun Lee

Background: Quadrimalleolar (QM) and quadrimalleolar-equivalent (QME) fractures expand the trimalleolar concept by adding an anterior osseous syndesmotic component (Chaput or Wagstaffe fragment). Outcomes after operative fixation remain incompletely defined. Methods: We retrospectively reviewed 36 consecutive patients (18 QM, 18 QME) who underwent open reduction and internal fixation between April 2019 and December 2024, with a minimum 12-month follow-up. All patients underwent a component-based operative treatment strategy comprising preoperative computed tomographic (CT) characterization of each malleolar and syndesmotic component, morphology-based management of anterior fragments, and intraoperative arthroscopic assessment of residual instability. Syndesmotic reduction was assessed on bilateral CT 1 cm proximal to the plafond using direct anterior and posterior differences, fibular translation, and fibular rotation, referenced to the contralateral ankle. Clinical outcomes included Olerud-Molander Ankle Score (OMAS) and visual analog scale (VAS). Results: Baseline demographics did not differ significantly between groups. QME injuries were predominantly SER (supination–external rotation) type IV/Weber B (94.4%), whereas QM showed an even distribution between SER and PER (pronation–external rotation) and between Weber B and C ( P = .01). No significant side-to-side differences were observed in any of the 4 parameters in either group at 1 year (all P > .05); given the limited sample size, these nonsignificant findings may be subject to a type II error. Intra- and interobserver reliabilities were excellent (intraclass correlation coefficient 0.901-0.988). Mean OMAS improved to 86.1 ± 6.8 (QM) and 85.3 ± 5.7 (QME); VAS decreased to 1.0 ± 0.7 in both (within-group P < .001; between-group P = .82). All fractures united; 3 minor wound complications resolved with local care. Conclusion: A component-based operative treatment strategy was safe and associated with maintained anatomic distal tibiofibular alignment and favorable short-term outcomes in both QM and QME. The absence of a control group precludes conclusions on clinical necessity or superiority, and combined evaluation of these biomechanically distinct patterns should be interpreted with caution. Level of Evidence: Level IV, retrospective comparative case series.

Background: In high-grade syndesmotic injuries involving combined disruption of the anterior inferior tibiofibular ligament (AITFL) and posterior inferior tibiofibular ligament (PITFL), most suture-tape augmentation techniques have focused on the AITFL alone. This study evaluated the clinical and radiologic outcomes of a suture-tape-only anterior and posterior (A-P) augmentation technique, with a primary focus on technical feasibility and maintenance of syndesmotic reduction. Methods: We retrospectively reviewed consecutive patients who underwent A-P syndesmotic augmentation using nonabsorbable suture tape, based on clinical and radiologic data available from January 2022 through April 2026. Complete disruption of both the AITFL and PITFL was confirmed arthroscopically and by direct visualization. Clinical outcomes were assessed using the Olerud–Molander Ankle Score (OMAS) and visual analog scale (VAS) preoperatively and at the 1-year postoperative assessment. Syndesmotic reduction was evaluated on bilateral computed tomography (CT) scans obtained 1 year postoperatively using the direct anterior difference (DAD), direct posterior difference (DPD), fibular translation (FT), and fibular rotation (FR), with the uninjured contralateral ankle serving as the reference. Results: Seven patients (mean age, 35.1 years; mean follow-up, 26.3 months) were included. At the 1-year postoperative assessment, the mean OMAS increased from 1.4 ± 3.8 to 86.4 ± 5.6, whereas the mean VAS score decreased from 8.1 ± 0.7 to 0.3 ± 0.5 (both p = 0.016), with preoperative scores obtained in the acute injury setting. For both observers, no individual absolute side-to-side difference exceeded the predefined malreduction threshold for any of the four CT parameters. Bony union was achieved in all cases. One patient developed a superficial wound complication, and no reoperations were required. Conclusions: In this small, selected case series, A-P suture-tape augmentation was technically feasible, and syndesmotic reduction was maintained at 1 year postoperatively in patients with combined AITFL and PITFL injuries. These preliminary findings warrant further evaluation in larger comparative studies.

Background: Posterior ankle pain has varied etiologies, with sural nerve (SN) entrapment contributing to posterolateral ankle discomfort. The SN is a pure sensory nerve that innervates the lateral ankle and foot up to the fifth metatarsal. Although SN pathologies are known, specific clinical features and management of neuropathy affecting the lateral calcaneal branch of the sural nerve (LCBSN), which supplies the lateral heel, are less defined. This condition is often exacerbated by repetitive ankle dorsiflexion in sports or external compression from tight footwear. We hypothesized that LCBSN lesions cause a distinct pattern of heel pain that is uniquely aggravated by ankle dorsiflexion or shoe contact, thereby distinguishing this entity from other causes of posterior ankle pain. Methods: This retrospective case series included 23 patients. We reviewed records of 23 patients presenting with posterolateral ankle pain and localized LCBSN tenderness. Key diagnostic features included pain aggravation with ankle dorsiflexion or shoe contact, lacking motor deficits. Diagnosis was primarily confirmed by immediate, significant pain relief after local anesthetic injection around the LCBSN. Symptom severity (0-4 scale) and American Orthopaedic Foot & Ankle Society (AOFAS)-hindfoot scores were assessed at 1 month and 1 year post-treatment. Surgical intervention was performed for recurrent pain after 6 months of conservative management. Results: Improvement ( P < .05) in both symptoms and AOFAS-hindfoot scores was observed at 1-month and 1-year follow-ups. Six patients required surgical treatment for recurrent symptoms. Pathologic findings included arterial wall thickening with dense perineural adhesions and scarring (3 cases), neuroma formation (2 cases), and nerve entrapment due to adhesions (1 case). Conservative treatment was effective for the remaining patients. Conclusion: Accurate and timely diagnosis of LCBSN lesions is crucial for effective treatment and enabling prompt return to sports activities. A diagnostic, small volume local anesthetic injection may serve as a practical diagnostic adjunct and an initial therapeutic measure for this clinically significant condition.

Background: Recent advancements in all-inside arthroscopic techniques for chronic ankle instability have shown promising outcomes. However, the necessity and clinical benefits of inferior extensor retinaculum (IER) reinforcement in arthroscopic lateral ligament complex (LLC) repair remain unclear. Purpose: To evaluate whether IER reinforcement in arthroscopic LLC repair improves clinical, radiologic, and functional outcomes as compared with isolated arthroscopic LLC repair without IER reinforcement. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: In this study, 59 patients who underwent arthroscopic surgery for chronic ankle instability were prospectively randomized into 2 groups: arthroscopic anterior talofibular ligament repair with (group W, n = 29) and without (group WO, n = 30) IER reinforcement. The primary outcome was the Foot and Ankle Outcome Score at the final follow-up. The visual analog scale for pain, American Orthopedic Foot & Ankle Society score, and Karlsson ankle function score were measured as subjective outcomes. Posturographic analysis, as an objective outcome, was performed with a Tetrax device. Radiologic outcome evaluations were performed preoperatively and 2 years postoperatively using stress radiographs and magnetic resonance imaging in axial view. Complications, including retears, neuralgia, and knot irritations, were recorded. Results: No significant differences were found between groups in clinical, proprioceptive, or radiologic outcomes at the final follow-up. Three retears (5.1%) were identified on postoperative MRI (group W, 3.4% [1/29]; group WO, 6.7% [2/30]; P = .580). Complications included knot irritation in 3 patients (10.3%) of group W and superficial peroneal nerve neuralgia in 1 patient (3.3%) of group WO. No significant differences in complications were observed between the groups. Conclusion: Arthroscopic LLC repair yields favorable clinical outcomes, regardless of whether IER reinforcement is performed. Given the lack of additional clinical benefit, routine IER reinforcement may not be warranted. Registration: Clinical Research Information Services (CRIS), Korea — Registration No.: [KCT0004755].

Background: Subtle Lisfranc injuries are low-energy, purely ligamentous lesions increasingly recognized in active patients; although screw fixation is common, Internal Brace (IB) flexible fixation is an alternative. Methods: In this multicenter retrospective study (2014–2021), 65 patients with subtle ligamentous Lisfranc injury (C1–M2 diastasis < 5 mm) underwent standard screw (SS, n = 35) or IB fixation (n = 30). Outcomes included AOFAS and VAS, standing radiographs and weight-bearing CT (WBCT) diastasis, pedobarography (4–6 months), and complications. Results: Demographics and injury mechanisms were similar. Both groups improved from preoperative status to final follow-up (p < 0.05). At 6 months, IB had higher AOFAS and lower VAS than SS (p < 0.05). Final stability was comparable: standing C1–M2 diastasis 2.54 mm (IB) vs. 2.55 mm (SS); WBCT dorsal 1.26 vs. 1.21 mm and plantar 3.58 vs. 3.42 mm (all NS). Pedobarography showed no significant side-to-side differences in either group. Complications favored IB: SS had screw breakage 11.4% (4/35), recurrent diastasis 2.9% (1/35), and early arthritis 5.7% (2/35); IB had no implant breakage, no severe recurrent diastasis, and no early arthritis. Conclusions: In this Level III study, IB fixation was associated with better 6-month clinical outcomes with similar final radiographic stability and fewer hardware-related complications versus SS.

Gyeong Hoon Lim, Dong-Il Chun, Min Hyeok Kim, Sung Hyun Lee. AOSM 2025;12:54-63. https://doi.org/10.14517/aosm25007

Objective: This study aimed to assess osteoarthritic changes in the ankle joint in a surgical model of chronic ankle instability (CAI) in mice. Methods: This experimental study was conducted this study using 14-week-old Institute of Cancer Research (ICR) male mice ( n = 19), divided into the sham control ([SH], n = 5), anterior talofibular ligament resection ([ATFL]; mild sprain, n = 7), and ATFL + calcaneofibular ligament resection ([ATFL + CFL]; severe ankle injury, n = 7) groups. A combination of behavioral analysis, micro-computed tomography, immunohistochemical staining, and serological analysis through enzyme-linked immunosorbent assay was performed to evaluate the outcomes. Results: A decrease in hind-leg standing was observed in the injured mouse groups, indicating signs of discomfort. Significant deterioration in cartilage integrity and joint structure was quantitatively confirmed in the ATFL + CFL group. Increased cartilage erosion and subchondral bone damage were observed. Serological analysis revealed elevated levels of inflammatory cytokines (TNF-α, IL-6, and IL-1β) in the ATFL + CFL group, suggesting a heightened inflammatory response. Conclusions: This study demonstrated that severe CAI, particularly that involving both the ATFL and CFL, directly contributes to the development of ankle osteoarthritis. This highlights the critical need for targeted interventions in preventing or mitigating this progression.

Purpose: To evaluate the clinical outcomes of arthroscopic all‐inside anterior talofibular ligament (ATFL) repair on the basis of the quality of the remnant ATFL. Methods: We retrospectively analyzed consecutive patients with chronic ankle instability who underwent arthroscopic ATFL repair with a minimum follow‐up period of 24 months. Patients were categorized into 2 groups on the basis of the arthroscopic ATFL grade: group G, characterized by good‐to‐moderate tissue quality with distension or ATFL discontinuity; and group P, characterized by poor tissue quality with a hypoplastic ATFL. Outcome measurements were obtained preoperatively and postoperatively. Patients‐reported outcomes were assessed using the visual analog scale score, Foot and Ankle Outcome Score (FAOS), and Karlsson ankle functional score. Objective outcomes included posturographic analysis and radiologic evaluations, such as stress radiographs and axial view magnetic resonance imaging. Results: Both groups exhibited postoperative improvements in the subjective and objective clinical outcomes (all P < .05). For the sports unit of FAOS, 75.3% of group G exceeded the minimal clinically important difference threshold, compared with 57.8% of group P, showing a statistically significant difference ( P = .027). Group P had significantly lower FAOS scores in the sports unit (group G: 86.9 ± 32.8, group P: 61.9 ± 26.4, P = .016), an increased fall risk as determined using posturography at the final follow‐up (group G: 28.6 ± 22.4, group P: 49.7 ± 23.3, P = .019), and a greater retear rate on axial‐view MRI (group G: 2.6%, 2/77, group P: 10.9%, 7/64, P = .044). Conclusions: Arthroscopic all‐inside ATFL repair is an effective treatment for chronic ankle instability, regardless of the quality of the remnant ligament. However, patients with poor ligament quality have inferior clinical outcomes, particularly in terms of sports‐related activities, as reflected by both lower scores and fewer patients exceeding the minimal clinically important difference threshold. In addition, the fall risk index and retear rates were greater in patients with poor ligament quality, highlighting the impact of ligament quality on postoperative stability and functional recovery. Level of Evidence: Level III, retrospective cohort study.

Gab-Lae Kim, Seung Hwan Han, Kwang Hwan Park, Dae-Yoo Kim, Gyeong Hoon Lim, Sung Hyun Lee. JKFAS 2025;29:1-8. https://doi.org/10.14193/jkfas.2025.29.1.1