Name: Case Presentation: Rationale Behind Multidirectional Ankle Instability
Uploaded: 2026-06-23T00:00:00Z
Channel: Arthrex
Description: Cesar de Cesar Netto, MD, PhD (Durham, NC), explains the classification, diagnosis, and treatment rationale of multidirectional ankle instability.

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Cesar de Cesar Netto, MD, PhD (Durham, NC), explains the classification, diagnosis, and treatment rationale of multidirectional ankle instability.

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VID1-009625-en-US | B | Case Presentation: Rationale Behind Multidirectional Ankle Instability

Cesar de Cesar Netto, MD, PhD

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Case Presentation: Rationale Behind Multidirectional Ankle Instability

Speaker  Hi, my name is Cesar de Souza Neto. I'm an associate professor at Duke University, and we're going to be talking about the rationale behind multidirectional ankle instability. When you're sprain your ankle, your foot is stuck on the ground, your body is moving forward, your body continues to go forward and internally rotates, while your foot in consequence externally rotates. So there's always this external rotation component. And is it really possible that with that only one single ligament would be injured and in the literature kind of is going towards that direction with the concept that there's no such a thing as a simple ankle sprain, and that we might be underestimating our enemy. And that's what the literature actually shows. This is a systematic review that actually shows that up to 33% of patients that had an ankle sprain are still having pain after a year, and you would expect that in three years they would all be healed. But no, there are still issues up to 85% of the patients. This is a classic paper by Doctor Hintermann, where he was treating patients with what we treat most frequently, and he was scoping out doing arthroscopic assessment of all this patients. And he pointed out that when he looked for deltoid ligament injury in combination with the chronic lateral ankle instability, he found 40% of the cases to have signs of deltoid ligament dysfunction. And 9% of the syndesmosis were also chronically injured in his assessment. So highlighting this big numbers 40 and 9%. So we talked about what is multidirectional instability, right? If you go into the literature, when people say multidirectional ankle instability, they're talking about a combination of lateral and medial ankle instability. Speaker  So how would we call medial lateral syndesmosis. I don't know. That's what I call multidirectional instability. The combination of the three, again in the literature, medial and lateral is what has been utilized as the terminology. And here's one example of a cohort of 30 patients with medial and lateral instability that were treated with arthroscopic assessment, arthroscopic debridement, medial and lateral brostrom. And these patients did great. They did very well in these scenarios. The majority of time surgeons are reconstructing the superficial, deep, sorry, the superficial deltoid, only not the deep deltoid. What I think is usually the most important enemy. If we look into the the epidemiology of ankle arthritis, we can see that we're not doing a great job in treating ankle sprains. And we're also not doing a great job on treating ankle fractures. This is a classic paper out of Iowa, where 70% of the patients with end stage arthritis of the ankle were post-traumatic, as we know, as the most common cause for ankle arthritis. But if you look into the numbers, ankle fractures and ankle sprains and instability, chronic instability were really close to each other in terms of being the most common causes for end stage ankle arthritis. So it's pretty, pretty significant numbers. And that means that we have a lot to do better in terms of treating these injuries. And so there's multiple reasons for that. But I like to think and my my thoughts are that subtle residual syndesmotic instability and subtle residual deltoid instability are the ones to blame for the results not being that good. Speaker  And if you can diagnose that, if you are not looking for it, then you're not going to treat it. So I started seeing a lot of patients with chronic pain after one or more than one multiple ankle injuries. And when I was going to look into the MRI of these patients and examine them clinically, I was suspecting that more than one ligament and frequently all of them medial lateral and syndesmosis were affected. So this is a study under review. A prospective cohort of patients that are treated surgically. A total of 29 patients with chronic pain and or instability following rotational ankle injuries. 89% of them had ankle sprains. 11% had ankle fractures. And when I tested them under anesthesia for lateral ankle instability with a rotatory internal drawer test, 96% of the patients had instability compared to the contralateral side. When I assessed the Syndesmosis using a three millimetres sphere as a diagnostic test, 78% of the patients had syndesmotic instability confirmed arthroscopically. And when I asked for enter or deep deltoid instability with a positive drive through sign with a three millimetres shaver, or with direct visualization and gapping with external rotation test, 81% of the patients had instability on the medial side. So when we talk about the combination of the injuries. So if you talk about syndesmosis plus medial plus lateral, that's what I call multidirectional instability. 59% of these patients had all three together. 19% of the patients had medial and lateral instability, what I call rotational instability. 15% of the patients had syndesmotic and lateral instability, what I call anterolateral instability. Speaker  And only 4% of the patients had syndesmotic and deltoid instability, what I call anteromedial instability. If you pay attention to the graphical plot, you will see that only one patient 4% had isolated lateral ankle instability. What is an alarming number? These patients, when treated with stabilization, they do tremendously well in terms of patient reported outcomes, and they're able to go back to their lives. We did publish this nomenclature that I just mentioned to you guys about the isolated injuries, the combined injuries, rotational, anterolateral, anteromedial and multidirectional. And you have to remember that there's also the subtalar joint that could be affected. And so if you have an instability of the subtalar joint, you have to add that to the nomenclature. And this is up to date, updated version of my data with both my practices where the multidirectional are still the most frequent one. So all the three ligaments together, 52%, followed by the rotational medial and lateral instability, 27%, followed by intra lateral that is, lateral and syndesmosis, but no medial 17%, followed by isolated lateral. Only 3% of the cases when you check were only isolated. Chronic lateral ankle instability again alarming number followed by anteromedial. That would be syndesmosis and medial but no lateral. I believe that we're definitely underestimating our opponent, and that's probably why we have so many post-traumatic ankle arthritis. I think we can do a better job, and for us to do a better job to be able to decide in treating this, we need to diagnose it and we have to think about it. So definitely we need to pay more attention. Speaker  To.

Lateral Ankle Ligament Reconstruction

Case Presentation: Rationale Behind Multidirectional Ankle Instability

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