Biomechanical assessment of ligament maturation after arthroscopic ligament reconstruction of the anterior talofibular ligament

Grégoire Rougereau; Tristan Langlais; Marc Elkaim; Manon Bachy; Thomas Bauer; Raphael Vialle; Alexandre Hardy

doi:10.1016/j.otsr.2025.104162

Biomechanical assessment of ligament maturation after arthroscopic ligament reconstruction of the anterior talofibular ligament

Orthop Traumatol Surg Res. 2025 Jan 11:104162. doi: 10.1016/j.otsr.2025.104162. Online ahead of print.

Authors

Grégoire Rougereau¹, Tristan Langlais², Marc Elkaim³, Manon Bachy⁴, Thomas Bauer⁵, Raphael Vialle⁶, Alexandre Hardy⁷

Affiliations

¹ Department of Orthopedics and Traumatology, Ambroise-Paré Hospital, AP-HP, Île-de-France Ouest University, Boulogne-Billancourt, France. Electronic address: dr.rougereau@chirurgiedusport.com.
² Department of Paediatric Orthopedic Surgery, Purpan Hospital, Toulouse University, Toulouse, France.
³ Department of Orthopedic Surgery, Clinique Drout Laffitte, Paris, France.
⁴ Department of Paediatric Orthopedic Surgery, Armand-Trousseau Hospital, AP-HP, Sorbonne University, Paris, France.
⁵ Department of Orthopedics and Traumatology, Ambroise-Paré Hospital, AP-HP, Île-de-France Ouest University, Boulogne-Billancourt, France.
⁶ Department of Paediatric Orthopedic Surgery, Armand-Trousseau Hospital, AP-HP, Sorbonne University, Paris, France; The MAMUTH Hospital University Department for Innovative Therapies in Musculoskeletal Disease Sorbonne University, Paris, France.
⁷ Department of Orthopedic Surgery, Clinique du Sport, 36 Boulevard Saint-Marcel, 75005 Paris, France.

PMID: 39805548
DOI: 10.1016/j.otsr.2025.104162

Abstract

Background: Many techniques have been described for lateral ankle ligament reconstruction. Although the biomechanical properties of gracilis tendons are different from those of ligaments, the use of a gracilis tendon autograft is a popular option for anatomical reconstruction. Graft maturation and the biomechanical processes over time remain unclear. This study describes changes in graft stiffness following anterior talofibular ligament (ATFL) reconstruction and graft reaction to varus stress.

Hypothesis: The reconstruction would be stiffer than the native ATFL, but would decrease during follow-up.

Methods: Twenty patients were prospectively included after arthroscopic reconstruction of the ATFL and calcaneofibular ligament for ankle stabilization. All patients were followed up 3, 6, and 12 months after surgery to assess graft stiffness by shear wave elastography (SWE) at different angles of varus in the ankle. At one year the EFAS and AOFAS functional scores were obtained. A control group of twenty healthy subjects were included to compare graft stiffness to that of a native ATFL.

Results: The stiffness of the native ATFL in the control group was 12.8 +/- 2.4 kPa in neutral position, 18.4 +/- 4.8 kPa at 15 ° of varus, 31.9 +/- 6.6 kPa at 30 ° of varus. One year after surgery, graft stiffness was statistically higher and averaged 56 +/- 9 kPa, 70.2 +/- 11.6 kPa and 84.9 +/- 10.5 kPa, respectively. Postoperative graft stiffness at three, six, and twelve months was not correlated with any of these scores, reflecting patient satisfaction and good function at one year.

Conclusion: Graft stiffness decreases over time but remains four times stiffer than that of a native ATFL at one year in the neutral position. ATFL graft stiffness at one year during varus stress appears to be different from that of a native ATFL.

Level of evidence: III.

Keywords: Anatomical reconstruction; Chronic ankle instability; Ligamentisation; Shear wave elastography.