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Original Article
Chronic ankle instability: Arthroscopic anatomical repair
Inestabilidad crónica de tobillo: reparación anatómica artroscópica
M. Arroyo-Hernándeza,
Corresponding author
martaarroyohdz@hotmail.com

Corresponding author.
, M. Mellado-Romeroa, P. Páramo-Díaza, L. García-Lamasa, J. Vilà-Ricoa,b
a Unidad de Artroscopia, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, Spain
b Departamento de Cirugía, Universidad Complutense de Madrid, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Sprained ankles are one of the most frequent musculo-skeletal pathologies&#44; constituting more than 10&#37; of daily traumatological emergencies&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a> The most common mechanism of lesion is ankle inversion with the foot in plantar flexion&#46; In this position&#44; the anterior talofibular ligament talofibular anterior &#40;ATFL&#41; acts as the main stabiliser of the ankle&#46; This ligament is the weakest in the lateral ligament complex&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a> The initial treatment in the great majority of ankle sprains is conservative&#44; with a high percentage of good results&#46; This treatment should include a complete programme of rehabilitation&#44; with proper proprioception exercises&#46; In spite of this conservative treatment&#44; there have been reports of failure in between 20&#37; and 40&#37; of the cases&#44; which end up developing chronic ankle instability&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Chronic lateral ankle instability can be linked to multiple pathologies&#44; both intra-articular and extra-articular&#44; as well as varus misalignment of the hindfoot&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">4&#8211;6</span></a> When conservative treatment of chronic ankle instability fails&#44; surgical treatment is indicated&#46; Numerous surgical techniques to approach this pathology have been described&#44; with direct anatomical repair being the &#8220;gold standard&#8221;&#46; This technique of open surgery was described by Brostr&#246;m in 1966<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a>&#59; after that&#44; modifications of this technique and techniques arthroscopic anatomical repair have been described&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">8&#44;9</span></a> However&#44; the success of such repair depends on the quality of the residual tissue&#46; In patients with long-term ankle instability&#44; with poor quality residual tissue&#44; obesity or severe deformities associated&#44; anatomical reconstruction with plasties might be indicated&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Several techniques for arthroscopic repair of the ATFL&#44; without associated percutaneous manoeuvres &#40;all-inside&#41;&#44; have recently been described&#46; These techniques allow treating both the instability and the associated intra-articular lesions in the same operation&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">2&#44;12&#8211;14</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The objectives of this study were to assess the preliminary results of all-inside arthroscopic anatomical repair of the ATFL and to analyse the intra-articular lesions associated&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and method</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study population</span><p id="par0025" class="elsevierStylePara elsevierViewall">Between May 2012 and January 2013&#44; a total of 21 patients were surgically intervened for lateral chronic ankle instability in our centre&#46; With respect to distribution by sex&#44; 15 patients were male and 6 were female&#59; mean age was 30&#46;43 years &#40;range&#58; 18&#8211;48 years&#41;&#46; Mean follow-up was 29 months &#40;range&#58; 25&#8211;33 months&#41;&#46; All the patients were treated using the all-inside technique of arthroscopic anatomical repair&#44; always by the same surgeon&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Criteria of inclusion</span><p id="par0030" class="elsevierStylePara elsevierViewall">As criteria of inclusion in the study&#44; to guarantee the viability of the tissue repaired&#44; we included patients with a maximum of 3 ankle sprains&#44; with the last of them being of fewer than 9 months of evolution&#46; The mean number of episodes was 2&#46;36 &#40;range&#58; 1&#8211;3 episodes&#41;&#44; with a mean time since the last inversion trauma of 6&#46;7 months &#40;range&#58; 3&#8211;9 months&#41;&#46; Patients with obesity&#44; recurrence over prior direct repair&#44; severe associated deformities or neuromuscular diseases and high sport demand patients were excluded&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Only patients that had complied with a minimum postoperative follow-up of 6 months&#44; attending periodic revisions regularly&#44; were studied&#46; The revisions were established during the early postoperative period at 2&#44; 4&#44; 8 and 12 weeks and&#44; after that&#44; at 6 months and the first year postoperatively&#46; All the patients studied had carried out a specific postoperative rehabilitation programme&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Clinically&#44; all the patients had a history of previous ankle sprain as relevant trauma&#46; They presented pain spontaneously and upon palpating the lateral side of the ankle&#46; The patients reported sensations of instability and failure during their daily and&#47;or sport activities&#46; The physical examination revealed a varus deformity of the hindfoot in 4 patients&#46; The manoeuvres for exploration of ankle instability&#44; as well as the anterolateral translation test and the varus stress test&#44; were positive in all the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">As complementary tests&#44; load X-rays were performed&#44; including the Saltzman projection&#44; as well as magnetic resonance imaging &#40;MRI&#41;&#44; in all the cases&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">17</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The results were evaluated based on the American Orthopaedic Foot and Ankle Society &#40;AOFAS&#41; scale<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">18</span></a> before surgery and at 18 months postoperative follow-up&#46; This gave us the data for a functional-clinical study&#44; analysing the results of the AOFAS scale and the moment of restarting prior sport activity&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Surgical technique</span><p id="par0055" class="elsevierStylePara elsevierViewall">In all the cases&#44; the surgical intervention was performed under intrathecal regional anaesthesia&#46; As antibiotic prophylaxis&#44; 2<span class="elsevierStyleHsp" style=""></span>g of intravenous &#40;i&#46;v&#46;&#41; cephalosporin was administered&#59; if the patient was allergic to the beta-lactams&#44; we used 1<span class="elsevierStyleHsp" style=""></span>g i&#46;v&#46; vancomycin&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">As for the operation itself&#44; the patient was placed in the supine position&#46; Ischaemia of the limb was performed with a pressure cuff located at the root of the member&#46; The limb affected was positioned with a flexion of the hip and knee of approximately 30&#176; and a support under the proximal third of the leg&#44; so that the ankle was parallel to the floor and free of supports and the operating table&#46; This was done to enable all the plantar and dorsal flexion movements that would be needed during the surgery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The ankle arthroscopy was carried out using the classic anteromedial and anterolateral portals&#46; No accessory portals were needed in any of the cases&#46; The associated lesions&#44; such as the peroneal tendons&#44; posterior ankle pinching syndrome or osteochondral lesions &#40;OCL&#41;&#44; were surgically treated during the same surgical intervention&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The cases of varus misalignment of the hindfoot were also treated in the same surgical intervention&#44; associating an osteotomy of lateral calcaneus sliding&#44; before the arthroscopy was performed&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The anterior chamber was arthroscopically explored completely&#44; with treatment of the associated lesions&#46; The ATFL was then repaired under direct vision&#46; The first step was the insertion of the ATFL in the fibula&#59; to do so&#44; the bony landmark was debrided through the anterolateral portal &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The remainder of the ATFL was pierced&#44; from lateral to medial&#44; with a Micro SutureLasso &#40;Arthrex&#44; Naples&#44; FL&#44; USA&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The fiberwire was passed and&#44; through it&#44; a double 2&#47;0 high-resistance suture&#46; All these surgical steps were carried out through the anterolateral portal&#44; with the optics located in the anteromedial portal&#46; The same manoeuvre was then repeated with a second suture point proximal to the previous one&#46; In that way&#44; the surgeon could pull on the rest of the ligament to ascertain the quality of the tissue to be repaired&#46; The drill guide was then inserted through the anterolateral portal and placed in the bony landmark of the ATFL&#44; just distal to the insertion of the distal anterior inferior tibiofibular ligament &#40;DAITFL&#41;&#46; The 2&#46;0-mm drill was directed from anterior to posterior&#44; parallel to the plantar plane and to the lateral aspect&#46; Next&#44; the 2 holes were drilled&#44; vertically in the bony landmark &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A&#41;&#46; After that&#44; the most distal suture point was passed through a 2&#46;5-mm knotless Bio-PushLock anchor &#40;Arthrex&#44; Naples&#44; FL&#44; USA&#41; and introduced in the first hole &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>B&#41;&#46; During the implantation of the Bio-PushLock anchor&#44; it was important to maintain a fixed foot position&#44; in a slight dorsal flexion of 5&#176; and eversion of 5&#176;&#8211;10&#176;&#46; The same process was repeated with the second suture point &#40;the most proximal&#41;&#46; We prefer to use 2 implants because they permit greater surface contact of the ATFL with the fibular bony landmark&#44; as well as better distribution of the tensions&#44; from a biomechanical point of view &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>C&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Following proper postoperative protocol was important&#46; Following the intervention&#44; the ankle had to be immobilised with an orthopaedic splint&#44; having the ankle in neutral position &#40;90&#176;&#41; and slight eversion &#40;10&#176;&#41;&#44; for 3 weeks&#46; After that&#44; it was replaced with a Walker-type orthosis &#40;DonJoy&#44; Surrey&#44; UK&#41;&#46; From 1 month postoperative&#44; the patient began with progressive partial load&#44; using 2 crutches based on tolerance&#44; and the patient started a rehabilitation programme&#46; If treatment of OCL was required&#44; the patient remained off the foot for a period of 4&#8211;6 weeks&#46; The patients who underwent calcaneus osteotomy received the same postoperative protocols indicated previously&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">From 8 weeks postoperative&#44; the patients began to carry out specific sport activities that did not involve physical contact &#40;swimming and static or elliptical cycling&#41;&#44; beginning continuous running at 10&#8211;12 weeks&#46; The patients could commence their usual sport activities again in a progressive and controlled manner after some 4 and 6 months&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">A total of 21 patients with chronic ankle instability were surgically treated in our hospital&#44; with arthroscopic anatomical repair of the ATFL being performed in all of the cases&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In 4 patients &#40;19&#37;&#41;&#44; physical examination yielded the diagnosis of a varus deformity of the hindfoot associated with lateral ankle instability&#46; This deformity was treated in the same intervention&#44; carrying out an inverse Koutsogiannis osteotomy&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">19</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">As for the X-ray results&#44; the various projections used confirmed varus misalignment of the hindfoot in 4 patients and diagnosed posterior impingement of the joint in 3 patients&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">An ATFL lesion was the conclusion in 100&#37; of the MRI reports&#46; With respect to the associated lesions found&#44; the results were as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall">In 6 cases &#40;28&#46;57&#37;&#41;&#44; there was an OCL associated&#44; which was later confirmed at the time of the associated OCL arthroscopy in all of them&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0115" class="elsevierStylePara elsevierViewall">In 3 cases &#40;9&#46;52&#37;&#41;&#44; there was a posterior impingement of the joint&#44; which was confirmed with the arthroscopy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0120" class="elsevierStylePara elsevierViewall">The finding most often associated with ATFL rupture in the MRI was the partial rupture of the peroneus brevis tendon&#44; found in 9 patients &#40;42&#46;86&#37;&#41;&#46; However&#44; in the intervention&#44; it was seen that in 6 of the patients there was no type of associated pathology&#46; In 1 case&#44; the only associated finding was a posterior ankle impingement &#40;also seen in the MRI&#41;&#59; in 2 patients&#44; peroneal tendon lesions were indeed found&#58; 1 case of intrasheath luxation and 1 case of partial rupture of the peroneus brevis tendon&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0125" class="elsevierStylePara elsevierViewall">Lastly&#44; in 4 patients &#40;19&#46;04&#37;&#41;&#44; the MRI revealed the ATFL lesion associated with a complete rupture of the peroneus brevis tendon&#46; In those cases&#44; there was no good correlation with the intraoperative findings either&#46; During the intervention&#44; 2 cases of partial peroneus brevis tendon&#44; 1 case of intrasheath luxation and 1 case of isolated tenosynovitis were found&#46;</p></li></ul></p><p id="par0130" class="elsevierStylePara elsevierViewall">As for the intraoperative results&#44; intra-articular lesions were diagnosed in 15 patients &#40;71&#46;4&#37;&#41;&#46; A total of 6 patients presented OCL&#44; posterior impingement of the ankle was found in 3 patients and&#44; in 6 patients&#44; some type of pathology of the peroneal tendons was found&#46; All of these lesions were surgically approached in the same surgical intervention &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Of the 6 cases with OCL &#40;28&#46;5&#37;&#41;&#44; 4 cases were grade IIIB and 2 cases were grade IV of the International Cartilage Repair Society &#40;ICRS&#41;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">20</span></a> classification&#46; All the cases were treated with bone marrow stimulation techniques&#44; which consisted of debridement of the lesion and microperforations&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The 3 cases with posterior ankle impingement &#40;14&#46;2&#37;&#41; were treated by osteophyte resection&#44; by means of the posterior endoscopic portals described by Van Dijk&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">21</span></a> In these cases&#44; it was necessary to reposition the patient in the prone position&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The 6 patients with pathology of the peroneal tendons &#40;26&#46;5&#37;&#41; required tendoscopic surgery&#58; in 1 case&#44; the finding was isolated tenosynovitis&#59; in 3 cases&#44; partial rupture of the peroneus brevis tendon was found and 2 cases presented intrasheath luxation&#46; The 4 cases with tenosynovitis and partial ruptures were treated using tendoscopic synovectomy&#44; while the 2 patients with intrasheath luxation required tendoscopic deepening of the peroneal sulcus&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">22</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">A functional-clinical review was carried out&#44; using the AOFAS scale&#46; The mean preoperative AOFAS was 66&#46;12 points &#40;range&#58; 60&#8211;71&#41;&#44; while the postoperative AOFAS increased to a mean of 96&#46;95 points &#40;range&#58; 90&#8211;100&#41;&#46; All of the patients could take up their previous sport activities again in a mean of 21&#46;5 weeks &#40;range&#58; 17&#8211;28&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">We found complications in 3 patients &#40;14&#37;&#41;&#46; The first patient presented joint rigidity&#44; which required arthroscopic debridement and immediate rehabilitation&#59; the final result was good&#46; Another patient presented infection of the arthroscopic portals&#44; with superficial cellulitis&#59; this patient was treated with oral antibiotics and evolved satisfactorily&#46; Lastly&#44; there was 1 case of neuropathy of the superficial peroneal nerve&#44; which also evolved favourably&#44; without any current symptoms&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0160" class="elsevierStylePara elsevierViewall">Sprained ankles are the most frequent cause of injury to the lateral ankle ligament complex&#46; In the majority of the cases&#44; they are treated as a banal pathology&#46; However&#44; the percentage of patients that develop chronic ankle instability after this injury ranges between 20&#37; and 40&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">With these patients&#44; it is essential to take an appropriate clinical history and physical examination&#46; The physical exam should focus on ruling out factors predisposing for chronic ankle instability&#44; such as the coexistence of varus hindfoot or fixed plantar flexion of the first metatarsal&#46; These deformities should be treated surgically&#44; during the same operation&#44; given that they are the fundamental reason for failure of surgical treatment of chronic ankle instability&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">23</span></a> Likewise&#44; complementary imaging tests should be performed&#46; These are very useful for ruling out associated intra-articular pathologies&#44; such as OCL&#44; fractures&#44; peroneal tendon pathology and joint impingements&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Kim et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">24</span></a> analysed the validity of MRI images in the diagnosis of ATFL lesions and the relationship with arthroscopic findings&#46; As indicated in their article&#44; they conclude MRI sensitivity and positive predictive value for the diagnosis of ATFL lesions are very high&#46; In our study&#44; there is also excellent correlation between the MRI reports and the arthroscopic findings&#44; with respect to the diagnosis of ATFL lesions&#59; the ATFL lesion was reported in 100&#37; of the cases&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">However&#44; we have not found any studies published that specifically analyse the correlation of radiological and arthroscopic findings with respect to associated lesions&#46; Small size lesions are difficult to diagnose using MRI&#59; this is the reason why many authors recommend that arthroscopic examination of the ankle should routinely be performed before treatment of chronic ankle instability&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">25&#44;26</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Lee et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">4</span></a> studied the associated intra-articular lesions in patients with chronic ankle instability&#46; They found 100&#37; anterolateral synovitis&#44; 30&#37; superficial lesions of the talus cartilage with 7&#37; of OCL&#44; 14&#37; anterolateral articular impingement&#44; 14&#37; with anterior osteophyte in the distal tibia and 11&#37; with presence of free joint bodies&#46; Hintermann et al&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">25</span></a> described damage to the joint cartilage in up to 66&#37; of the cases and Ferkel and Chams<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">26</span></a> found intra-articular lesions even in 95&#37;&#46; These finding agree with those of our series&#44; in which we found associated lesions in up to 71&#37; of the cases&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Arthroscopic ankle surgery is currently a technique in constant evolution&#46; Arthroscopic treatment of patients with chronic ankle instability makes diagnosis and treatment of all these associated intra-articular pathologies possible&#46; Hawkins<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a> was the first to describe&#44; in 1987&#44; ankle arthroscopy as a possible treatment for chronic ankle instability&#46; More recently&#44; other authors have described different arthroscopic techniques for this pathology&#44; with excellent results&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">2&#44;13&#44;14</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">The first surgical technique&#44; described by Hawkins&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a> used staples to re-anchor the ATFL&#46; Since then&#44; the evolution up to the most modern surgical techniques has been constant&#46; In 2013&#44; Cottom and Rigby<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">13</span></a> described an arthroscopic technique using osseous spears implanted in the ATFL landmark and a mini-open&#44; needed to introduce the suture knots&#46; Vega et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a> described their arthroscopic technique&#44; using implants without knots&#44; but with the need for a complementary portal in the most anterior part of the peroneal malleolus&#46; Our technique allows arthroscopic ATFL repair using implants without knots and without the need to make complementary portals&#46; Consequently&#44; we avoid the complications that stem from prominence of the suture knots&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Other complications described in the arthroscopic techniques are neuritis of the superficial peroneal nerve and of the sural nerve&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">28</span></a> It is a good idea to mark the subcutaneous path of the superficial peroneal nerve before beginning the ankle arthroscopy&#46; In addition&#44; it should be taken into account that this nerve can move laterally with ankle dorsiflexion&#59; when a position in plantar flexion and inversion is changed to one in 5&#176; dorsiflexion&#44; the nerve will displace laterally up to a mean of 3&#46;6<span class="elsevierStyleHsp" style=""></span>mm&#46; Damage to the sural nerve is much lower with all-inside arthroscopic techniques&#44; given that no cutaneous incisions are required&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">It is important to emphasise that this technique is aimed at isolated ATFL repair&#44; without involving any possible lesions of the calcaneofibular ligament &#40;CFL&#41;&#44; which may be injured in up to 15&#37; of the cases&#46; In 2011&#44; Lee et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">4</span></a> published a study on the long-term results &#40;10&#46;6 years of mean follow-up&#41; of the modified Brostr&#246;m technique&#44; with no associated procedure in the CFL&#46; They obtained a mean AOFAS score of 91 points and observed integrity of the repaired ATFL&#44; with slight anterior translation &#40;6&#46;9<span class="elsevierStyleHsp" style=""></span>mm against 6&#46;1<span class="elsevierStyleHsp" style=""></span>mm in the contralateral&#41;&#46; The measurements of CFL function were also satisfactory&#44; with a 3&#176; talar tilt in the ankle treated&#44; against 2&#46;5&#176; in the contralateral&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">As possible limitations of our study&#44; we should point out the relatively small number of cases studied&#44; as well as the retrospective nature&#44; with the lack of a control group&#46; Another limitation of the study is that the preoperative ankle instability is not quantified&#44; accepting the clinical diagnosis with radiographic support&#46; This is a common limitation for the majority of the studies on chronic ankle instability&#46; Prospective&#44; comparative and randomised studies will be needed to be able to state that arthroscopic surgery is superior to open surgery&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0210" class="elsevierStylePara elsevierViewall">Arthroscopic surgery is fundamental in confirming the existence of intra-articular lesions associated with chronic ankle instability and is essential if treatment for such lesions is necessary&#46; Among its advantages over open surgery worth pointing out are its lower aggressiveness&#44; less associated morbidity and its better aesthetic results&#46; Sin embargo&#44; its superiority over open surgery is yet to be demonstrated&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Anatomical repair by means of the all-inside technique presents excellent functional-clinical results&#44; with early patient reincorporation to sport activities and a low index of reinterventions and complications&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Level of evidence</span><p id="par0220" class="elsevierStylePara elsevierViewall">IV&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ethical disclosures</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Protection of people and animals</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that no experiments on human beings or on animals have been performed for this research&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Confidentiality of data</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Right to privacy and informed consent</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflict of interests</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "identificador" => "sec0045"
          "titulo" => "Level of evidence"
        ]
        10 => array:3 [
          "identificador" => "sec0050"
          "titulo" => "Ethical disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Protection of people and animals"
            ]
            1 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
        ]
        11 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Conflict of interests"
        ]
        12 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-03-05"
    "fechaAceptado" => "2016-10-18"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec820905"
          "palabras" => array:3 [
            0 => "Ankle instability"
            1 => "Ankle sprain"
            2 => "Ankle arthroscopy"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec820904"
          "palabras" => array:3 [
            0 => "Inestabilidad de tobillo"
            1 => "Esguince de tobillo"
            2 => "Artroscopia de tobillo"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ankle sprains are one of the most common injuries&#46; Despite appropriate conservative treatment&#44; approximately 20&#8211;40&#37; of patients continue to have chronic ankle instability and pain&#46; In 75&#8211;80&#37; of cases there is an isolated rupture of the anterior talofibular ligament&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective observational study was conducted on 21 patients surgically treated for chronic ankle instability by means of an arthroscopic anatomical repair&#44; between May 2012 and January 2013&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">There were 15 men and 6 women&#44; with a mean age of 30&#46;43 years &#40;range 18&#8211;48&#41;&#46; The mean follow-up was 29 months &#40;range 25&#8211;33&#41;&#46; All patients were treated by arthroscopic anatomical repair of anterior talofibular ligament&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Four &#40;19&#37;&#41; patients were found to have varus hindfoot deformity&#46; Associated injuries were present in 13 &#40;62&#37;&#41; patients&#46; There were 6 cases of osteochondral lesions&#44; 3 cases of posterior ankle impingement syndrome&#44; and 6 cases of peroneal pathology&#46; All these injuries were surgically treated in the same surgical time&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A clinical-functional study was performed using the American Orthopaedic Foot and Ankle Society &#40;AOFAS&#41; score&#46; The mean score before surgery was 66&#46;12 &#40;range 60&#8211;71&#41;&#44; and after surgery it increased up to a mean of 96&#46;95 &#40;range 90&#8211;100&#41;&#46; All patients were able to return to their previous sport activity within a mean of 21&#46;5 weeks &#40;range 17&#8211;28&#41;&#46; Complications were found in 3 &#40;14&#37;&#41; patients&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Arthroscopic anatomical ligament repair technique has excellent clinical-functional results with a low percentage of complications&#44; and enables patients to return to their previous sport activity within a short period of time&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and method"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los esguinces de tobillo son una de las patolog&#237;as traumatol&#243;gicas m&#225;s frecuentes&#46; A pesar de un tratamiento conservador adecuado&#44; este fracasa en el 20-40&#37; de los casos&#46; Estos pacientes suelen desarrollar una inestabilidad cr&#243;nica de tobillo&#46; En el 75-80&#37; de las ocasiones existe una rotura aislada del ligamento talofibular anterior&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo observacional de 21 pacientes intervenidos quir&#250;rgicamente mediante t&#233;cnica de reparaci&#243;n anat&#243;mica artrosc&#243;pica&#44; por inestabilidad lateral cr&#243;nica de tobillo&#44; entre mayo de 2012 y enero de 2013&#46; Se realiz&#243; un seguimiento medio de 29 meses &#40;rango de 25-33&#41;&#46; La distribuci&#243;n por sexos fue de 15 hombres y 6 mujeres&#59; la edad media fue de 30&#44;43 a&#241;os &#40;rango de 18-48&#41;&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En 4 pacientes &#40;19&#37;&#41;&#44; se diagnostic&#243; una deformidad en varo del retropi&#233; asociada&#46; En 15 pacientes &#40;71&#44;4&#37;&#41;&#44; se diagnosticaron lesiones intraarticulares&#58; 6 pacientes presentaron lesiones osteocondrales &#40;LOC&#41; talares&#44; 3 presentaban un pinzamiento posterior de tobillo y 6 pacientes presentaban distintas patolog&#237;as de los tendones peroneos&#46; Todas estas lesiones fueron abordadas quir&#250;rgicamente en el mismo acto quir&#250;rgico&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se llev&#243; a cabo una revisi&#243;n cl&#237;nico-funcional&#44; utilizando la escala <span class="elsevierStyleItalic">American Orthopaedic Foot and Ankle Society</span> &#40;AOFAS&#41;&#46; La media preoperatoria fue de 66&#44;12 puntos &#40;rango de 60-71&#41; y la postoperatoria se increment&#243; hasta una media de 96&#44;95 puntos &#40;rango de 90-100&#41;&#46; Todos los pacientes pudieron retomar sus actividades deportivas previas en una media de 21&#44;5 semanas &#40;rango de 17-28&#41;&#46; Encontramos complicaciones en 3 pacientes &#40;14&#37;&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">La reparaci&#243;n anat&#243;mica del ligamento talofibular anterior mediante esta t&#233;cnica presenta unos resultados cl&#237;nico-funcionales excelentes&#44; con una temprana reincorporaci&#243;n del paciente a sus actividades deportivas y un bajo &#237;ndice de reintervenciones y complicaciones&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todo"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Arroyo-Hern&#225;ndez M&#44; Mellado-Romero M&#44; P&#225;ramo-D&#237;az P&#44; Garc&#237;a-Lamas L&#44; Vil&#224;-Rico J&#46; Inestabilidad cr&#243;nica de tobillo&#58; reparaci&#243;n anat&#243;mica artrosc&#243;pica&#46; Rev Esp Cir Ortop Traumatol&#46; 2017&#59;61&#58;104&#8211;110&#46;</p>"
      ]
    ]
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      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
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        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The limb affected is placed with a flexion of the hip and knee of approximately 30&#176; and support for the proximal third of the leg&#44; so that the ankle is parallel to the floor and free of support&#46;</p>"
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        "etiqueta" => "Figure 2"
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        "figura" => array:1 [
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            "imagen" => "gr2.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Preparation of ATFL insertion in the fibula&#59; the bony landmark is debrided through the anterolateral portal&#46;</p>"
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        "etiqueta" => "Figure 3"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">The remainder of the ATFL is pierced&#44; from lateral to medial&#44; with a Micro Suture Lasso &#40;Arthrex&#44; Naples&#44; FL&#44; USA&#41;&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">&#40;1&#41; Drilling of two openings&#44; located vertically in the bony landmark&#59; &#40;2&#41; the most distal suture point is passed through a 2&#46;5-mm Biopush Lock knotless anchor &#40;Arthrex&#44; Naples&#44; FL&#44; USA&#41; and inserted into the first hole&#59; &#40;3&#41; 2 implants are used&#44; because they allow a greater surface contact of the ATFL with the fibular bony landmark&#44; as well as better tension distribution&#44; from the biomechanical point of view&#46;</p>"
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      4 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">AL&#58; anterolateral&#59; AOFAS&#58; American Orthopaedic Foot and Ankle Society&#59; ATFL&#58; anterior talofibular ligament&#59; BMS&#58; bone marrow stimulation techniques&#59; CO&#58; calcaneal osteotomy&#59; F&#58; female&#59; M&#58; male&#59; MRI 1&#58; ATFL lesion<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>OCL&#59; MRI 2&#58; ATFL lesion<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>posterior articular impingement&#59; MRI 3&#58; ATFL lesion<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>partial PB rupture&#59; MRI 4&#58; ATFL lesion<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>complete PB rupture&#59; OCL&#58; osteochondral lesions&#59; P&#58; posterior&#59; PB&#58; peroneus brevis tendon&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MRI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AL box&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P box&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Arthroscopic findings and associated lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Postoperative AOFAS score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Associated procedures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OCL III<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>varus hindfoot&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BMS<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intrasheath luxation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sulcus deepening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Posterior ankle impingement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Osteophyte resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OCL IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BMS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Varus hindfoot&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OCL III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BMS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#8211;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Posterior ankle impingement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Osteophyte resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partial PB rupture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tendoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OCL III<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>varus hindfoot&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BMS<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Posterior ankle impingement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Osteophyte resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intrasheath luxation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sulcus deepening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partial PB rupture<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>varus hindfoot&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tendoscopy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OCL III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BMS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tenosynovitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tendoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OCL IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BMS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partial PB rupture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tendoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1386073.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Description of the population studied&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:28 [
            0 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chronic ankle instability"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;B&#46; Gerstner Garces"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.fcl.2012.06.001"
                      "Revista" => array:6 [
                        "tituloSerie" => "Foot Ankle Clin"
                        "fecha" => "2012"
                        "volumen" => "17"
                        "paginaInicial" => "389"
                        "paginaFinal" => "398"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22938637"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46; Vega"
                            1 => "P&#46; Golan&#243;"
                            2 => "A&#46; Pellegrino"
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ISSN: 19888856
Original language: English
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