Anatomic reconstruction of the lateral ligament complex of the ankle using a gracilis autograft

Republication of "Fracture Through a Distal Fibular Tunnel Used for an Anatomic Lateral Ankle Ligament Reconstruction"

Anatomic lateral ankle ligament reconstruction using free tendon graft with osseous tunnels has become a popular technique for revision reconstruction of the lateral ankle ligaments. With the procedure's burgeoning popularity, an accompanying increase in postoperative complications is likely to occur. We report on one such complication: traumatic distal fibula fracture through the transosseous tunnels.

Current Concepts on Subtalar Instability

Subtalar instability remains a topic of debate, and its precise cause is still unknown. The mechanism of injury and clinical symptoms of ankle and subtalar instabilities largely overlap, resulting in many cases of isolated or combined subtalar instability that are often misdiagnosed. Neglecting the subtalar instability may lead to failure of conservative or surgical treatment and result in chronic ankle instability. Understanding the accurate anatomy and biomechanics of the subtalar joint, their interplay, and the contributions of the different subtalar soft tissue structures is fundamental to correctly diagnose and manage subtalar instability. An accurate diagnosis is crucial to correctly identify those patients with instability who may require conservative or surgical treatment. Many different nonsurgical and surgical approaches have been proposed to manage combined or isolated subtalar instability, and the clinician should be aware of available treatment options to make an informed decision. In this current concepts narrative review, we provide a comprehensive overview of the current knowledge on the anatomy, biomechanics, clinical and imaging diagnosis, nonsurgical and surgical treatment options, and outcomes after subtalar instability treatment.

Modified Broström-Gould With Gracilis Autograft Augmentation Surgery and Accelerated Noncasted Rehabilitation in High Demand Patients With Lateral Ankle Instability

Lateral ankle instability that has failed conservative management can be physically debilitating. Good outcomes are obtained from Broström-Gould augmented repair techniques, however there are few studies evaluating the use of a gracilis autograft augmentation coupled with an accelerated rehabilitation program in high functional demand patients. We believe that the modified Broström-Gould technique utilizing a Gracilis autograft will provide significant improvements in stability while maintaining normal ankle biomechanics in young, high demand patients. The prospective cohort study involved 19 patients (20 ankles) who underwent surgery for chronic lateral ankle instability by a single surgeon, at a single institution between October 2014 and April 2016. Patients were followed for 33.8 ± 11.7 (range 12-48) months. Patients were assessed both pre- and postoperatively for talar tilt angle radiographically and with both American Orthopaedic Foot and Ankle Society Ankle and Hindfoot scores and Karlsson-Peterson scores. A Tegner activity score was taken at the last follow-up. The mean American Orthopaedic Foot and Ankle Society score increased from 68.85 ± 10.57 to 91.56 ± 5.31 points (p < .01) and mean Karlsson-Peterson score increased from 50.9 ± 15.53 to 88.11 ± 8.64 points (p value <.01) when compared preoperatively to mean postoperative follow-up of 33.8 months. Tegner activity score was 7.05 ± 0.89 at last follow-up. The technique was found to be effective in treating chronic lateral ankle instability and in combination with an accelerated rehabilitation protocol, patients returned to their premorbid level of activity with improved stability and no significant effect on donor graft site morbidity.

Chronic Lateral Ankle Instability: Topical Review

Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries. Conservative management is the modality of choice for acute lateral ankle ligament injuries, and operative treatment is reserved for special cases. Failure after strict rehabilitation may be an indication for surgery. Several operative options are available, including anatomic repair, anatomic reconstruction, and tenodesis procedures. Anatomic repair can be performed when the quality of the damaged ligaments permits. Anatomic reconstruction with an autograft or allograft should be considered when the torn ligaments are not adequate. Ankle arthroscopy is a useful adjunct to ligamentous procedures, performed at the time of repair to identify and treat intra-articular conditions that may be associated with chronic ankle instability. Tenodesis techniques are not recommended because of their suboptimal long-term results related to the modification of ankle and hindfoot biomechanics.Level of Evidence: Level V, expert opinion.

[Lateral ligament reconstruction with autogenous partial peroneus longus tendon for chronic lateral ankle instability]

OBJECTIVE

To assess the effectiveness of lateral ligament reconstruction with autogenous partial peroneus longus tendon for chronic lateral ankle instability.

METHODS

Between September 2014 and November 2018, 32 patients (32 sides) with chronic lateral ankle instability were treated with lateral ankle ligament reconstruction by using autogenous anterior half of the peroneus longus tendon. There were 25 males and 7 females, with an average age of 28.5 years (range, 20-51 years). The disease duration was 6-41 months (mean, 8.9 months). The preoperative Karlsson-Peterson ankle score was 53.7±9.7. The talar tilt angle was (14.9±3.7)°, and the anterior talar translation was (8.2±2.8) mm. Six patients combined with osteochondral lesion of talus and 4 patients combined with bony impingement.

RESULTS

All incisions healed by first intention postoperatively. All patients were followed up 12-53 months (mean, 22.7 months). At last follow-up, the Karlsson-Peterson ankle score was 85.2±9.6; the talar tilt angle was (4.3±1.4)°; the anterior talar translation was (3.5±1.1) mm. There were significant differences in all indexes between pre- and post-operation ( P<0.05). Seventeen patients were very satisfied with the results, 10 patients were satisfied, 4 patients were normal, and 1 patient was unsatisfied. After operation, the ankle sprain occurred in 7 cases, the tenderness around the compression screws at calcaneus in 5 cases, the anterolateral pain of ankle joint over 6 months in 4 cases. No patient had discomfort around the reciepient sites. At last follow-up, the ultrasonography examination showed that there was no significant difference in the density and diameter between bilateral peroneus longus tendons in 12 cases.

CONCLUSION

For chronic lateral ankle instability, the lateral ankle ligament reconstruction with the autogenous partial peroneus longus tendon is a safe and effective surgical option.

Arthroscopic anterior talofibular ligament reconstructin in chronic ankle instability: Two years results

PURPOSE

In chronic lateral ankle instability, primary ligament repair is not always possible because of poor quality of the local tissues. A free autologous or allograft tendon graft or synthetic grafts are suitable alternative. We describe middle term results of arthroscopic reconstruction of the anterior talofibular ligament (ATFL) using a free autologous ipsilateral gracilis graft in patients with chronic ankle instability.

METHODS

Eleven patients with chronic lateral ankle instability with imaging evidence of isolated ATFL tear underwent arthroscopic reconstruction of the ATFL using a free ipsilateral gracilis graft. Functional and subjective assessment were performed after an average of 24 months following the index procedure.

RESULTS

At 24 months, all patients showed objective improvements. One patient reported transient dysaesthesiae on the dorsolateral aspect of the foot and heel.

CONCLUSIONS

Arthroscopic isolated reconstruction of the ATFL with a free ipsilateral gracilis grafts is safe, allowing restoration of joint stability and low surgical morbidity.

STUDY DESIGN

Case series.

The effectiveness of lateral ankle ligament reconstruction when treating chronic ankle instability: A systematic review and meta-analysis

Chronic ankle instability predominantly occurs due to multiple exercise-related diseases. Conservative treatment methods regarding this condition have not effectively improved in recent years, which is why more focus has been put on exploring different novel reconstruction procedures of the lateral ankle ligament for the treatment of chronic ankle instability.

OBJECTIVES

This study aims to obtain the overall effectiveness of various lateral ankle ligament reconstruction methods for chronic ankle ligament instability.

METHODS

We gathered data from PubMed and EMBASE databases using the keywords: ankle, malleolar, and reconstruction. Newcastle - Ottawa quality assessment was carried out for the obtained studies; effect volume combination and image drawing were performed by Stata14, and Excel was used for data statistics.

RESULTS

A total of 12 articles were included in the quantitative analysis by performing full-text reading and data inclusion. Among them, 476 patients (485 ankle joints) were treated. The results showed that the overall valid efficiency of "excellent" was 59% and "good" lateral ligament reconstruction was 26%, I²=87.3%, P = 0.000; the subgroup analysis anatomic reconstruction group I²=0.0%, P = 0.993; the autograft group I²=0.0%, P = 1.000; allograft group I²=0.0%, P = 0.993.

CONCLUSION

Reconstruction of the lateral ankle ligament is a relatively stable treatment for chronic ankle instability.

Tendon Regeneration After Partial-Thickness Peroneus Longus Tendon Harvesting: Magnetic Resonance Imaging Evaluation and In Vivo Animal Study

BACKGROUND

In recent years, the use of the anterior half of the peroneus longus tendon (AHPLT) as an autograft source for ligament reconstruction has gained popularity. However, no reports are available regarding tendon regeneration after harvesting of the AHPLT.

HYPOTHESIS

When half of the tendon is preserved during tendon harvesting, the quality of the regenerated tendon is better than that of the regenerated tendon after full-thickness harvesting.

STUDY DESIGN

Case series; Level of evidence, 4; controlled laboratory study.

METHODS

A total of 21 patients who underwent AHPLT harvesting for lower extremity ligament reconstruction participated in the magnetic resonance imaging (MRI) study to evaluate tendon regeneration 1 year after the harvesting. An in vivo animal study was performed to compare the quality of the regenerated tendon after partial-thickness and full-thickness tendon harvesting. A total of 30 adult female Sprague-Dawley rats were allocated to 2 groups-15 rats underwent partial-thickness Achilles tendon harvesting (partial-thickness harvesting [PTH] group), and 15 rats underwent full-thickness Achilles tendon harvesting (full-thickness harvesting [FTH] group). The quality of the regenerated tendons was compared 180 days after tendon harvesting.

RESULTS

All 21 patients showed regeneration of the peroneus longus tendon (PLT) (homogeneously dark on both T1- and T2-weighted sequences). The cross-sectional area of the regenerated tendon divided by that of the preoperative tendon was 92.6% and 84.5% at 4 cm and 9 cm proximal to the tip of the distal fibula, respectively. In the animal study, the mean histologic score was better for the PTH group compared with the FTH group (9.17 ± 1.35 vs 14.72 ± 0.74; P < .001). The ultimate strength and the stiffness of the regenerated Achilles tendon were significantly higher for the PTH group compared with the FTH group (35.5 ± 8.3 vs 22.4 ± 8.3 N, P = .004; and 31.6 ± 7.7 vs 23.5 ± 4.8 N/mm, P = .016).

CONCLUSION

The PLT was found to regenerate after partial-thickness harvesting on MRI. In the animal study, the quality of the regenerated tendon when half of the tendon was preserved during tendon harvesting was better than that after full-thickness tendon harvesting.

A New Individualized Three-Dimensional Printed Template for Lateral Ankle Ligament Reconstruction

Background

Anatomical reconstruction using a semitendinosus tendon autograft is one of the most widely-used techniques for chronic lateral ankle instability (CLAI), and it can result in good biomechanical recovery for patients. The purpose of this study was to investigate the outcome of a novel individualized three-dimensional printed guide template for lateral ankle ligament reconstruction compared with the traditional surgical methods.

Material/Methods

We retrospectively studied 34 patients with CLAI who required lateral ankle ligament reconstruction. Patients were randomly divided into 2 cohorts: the template group (18 patients) and the conventional group (16 patients). The average operation duration and number of radiation exposures were compared between the 2 cohorts. The displacement of anterior talar and talar tilt angle were recorded at the last follow-up, and Karlsson-Peterson score and American Orthopedic Foot and Ankle Society Score (AOFAS) were also compared.

Results

All patients had satisfactory ankle stability at the last follow-up. The average operation duration was 51.9±3.6 min and the average number of radiation exposures was 1.34±0.6 in the template group, and the average operation duration was 72.4±12.6 min and the average number of radiation exposures was 6.58±1.7 in the conventional group. Difference between the 2 cohorts was statistically significant. However, in AOFAS (95.2±2.5 vs. 94.9±2.2; P>0.01.) and Karlsson Score (94.7±3.6 vs. 93.8±4.1; P>0.01.), no significant differences were found between the 2 cohorts.

Conclusions

Both the template technique and the conventional method provided satisfactory outcomes for CLAI patients. However, the shorter operation duration and low number of radiation exposures in the template cohort suggest it is the better alternative for treatment of CLAI.

Reconstruction of the lateral ankle ligaments using the anterior half of peroneus longus tendon graft

BACKGROUND

This study aimed to report our institution's experience in the treatment of chronic lateral ankle instability using the anterior half of the peroneus longus tendon (AHPLT) to reconstruct the lateral ligament.

METHODS

This retrospective study included 32 consecutive patients with chronic lateral ankle instability who underwent surgery from January 2013 to December 2014. All patients had failed to resolve with conservative treatment. A total of 32 ankles underwent AHPLT transfer. Patients returned for a clinical and radiologic follow-up evaluation at an average of 28 (range, 24-35) months postoperatively. Outcomes were assessed by comparison of pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual analog scale pain scores, and Karlsson scores, and the radiographic assessment including talar tilt and anterior talar translation.

RESULTS

Thirty-two patients (32 ankles) (100%) returned for final evaluation. All patients had an excellent or good outcome on patient subjective self-assessment, pain scores, AOFAS scores, and Karlsson scores at final follow-up. Ankle range of motion was not affected by lateral ankle reconstruction. The talar tilt was significantly reduced from a preoperative mean of 14.1±4.2° to 3.4±1.3° postoperatively (P<.001), and the anterior drawer was significantly reduced from a preoperative mean of 13.8±3.4mm to 3.6±1.5mm after lateral ankle ligamentous reconstruction (P<.001).

CONCLUSIONS

AHPLT transfer to reconstruct the lateral ligament resulted in a high percentage of successful results, with excellent ankle stability and not affected of ankle motion.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Three-Dimensional computed tomography tunnel assessment of allograft anatomic reconstruction in chronic ankle instability: 33 cases

INTRODUCTION

Although clinical results of anatomic reconstruction using allograft are reportedly good, studies on how accurately the tunnel has been made after surgery are very rare. The purpose of this study was to analyze the postoperative locations of the tunnels through 3-dimensional computed tomography (3D-CT) after anatomic ligament reconstruction and to evaluate its clinical results.

HYPOTHESIS

We hypothesized that anatomic lateral ligament reconstruction could lead to excellent results in clinical outcomes by repositioning anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) accurately.

MATERIALS AND METHODS

Thirty-three special forces of soldiers who were diagnosed as chronic ankle instability (CAI) were included. Visual analogue scale (VAS), American orthopaedic foot and ankle society (AOFAS) ankle-hind foot functional scores, and Tegner activity scale were comparatively analyzed before the surgery and at final follow-up. The locations of the talar, fibular and calcaneal tunnels were evaluated with 3D-CT taken after the surgery. Talar tilt and anterior drawer displacement were measured on stress radiographs.

RESULTS

The mean follow-up period was 26.8±3.6 months. The VAS decreased from 6.9±1.6 to 1.7±1.3, AOFAS ankle-hindfoot functional score increased from 61.3±14.8 to 88.7±9.2, and Tegner activity scale improved from 5.3±1.2 to 6.4±1.3 (p<0.001). Talar tunnel for ATFL was located about68% of the way from the lateral talar process, and fibular tunnels for ATFL and CFL were approximately 52% and 20% of the way from the fibular tip. The calcaneus tunnel was approximately 17mm posterosuperior from the peroneal tubercle on 3D-CT. Talar tilt decreased from 15.8±4.8 to 3.9±2.1 degrees (p<0.001). There were excellent inter-observer agreements for CT evaluation (Kappa values were from 0.83 to 0.92). There was no relapse of lateral instability.

DISCUSSION

Anatomic reconstruction of the lateral ligaments using allograft and the interference screw for CAI showed good results in postoperative stability and subjective clinical evaluation by repositioning the location of ATFL and CFL accurately on radiological determination.

LEVEL OF EVIDENCE

IV, Case-series.

Surgical management of chronic lateral ankle instability: a meta-analysis

Background

A key point to surgical treatment of chronic lateral ankle instability is choosing a suitable surgical procedure. The purpose of this meta-analysis was to compare different surgical techniques for management of chronic lateral ankle instability.

Methods

We searched the Cochrane Library, MEDLINE, and EMBASE. All identified randomized and quasi-randomized controlled trials of operative treatment for chronic lateral ankle instability were included. Two review authors independently extracted data from each study and assessed risk of bias. Where appropriate, results of comparable studies were pooled.

Results

Seven randomized controlled trials were included for analysis. They fell in five clearly distinct groups.

One study comparing two different kinds of non-anatomic reconstruction procedures (dynamic and static tenodesis) found two clinical outcomes favoring static tenodesis: better clinical satisfaction and fewer subsequent sprains.

Two studies compared non-anatomic reconstruction versus anatomic repairment. In one study, nerve damage was more frequent in non-anatomic reconstruction group; the other one reported that radiological measurement of ankle laxity showed that non-anatomic reconstruction provided higher reduction of talar tilt angle.

Two studies comparing two anatomic repairment surgical techniques (transosseous suture versus imbrication) showed no significant difference in any clinical outcome at the follow-up except operation time.

One study compared two different anatomic repairment techniques. They found that the double anchor technique was superior with respect to the reduction of talar tilt than single anchor technique.

One study compared an anatomic reconstruction procedure with a modified Brostrom technique. Primary reconstruction combined with ligament advanced reinforcement system results in better patient-scored clinical outcome, at 2 years post-surgery, than the modified Brostrom procedure.

Conclusions

There is limited evidence to support any one surgical technique over another surgical technique for chronic lateral ankle instability, but based on the evidence, we could still get some conclusions: (1) There are limitations to the use of dynamic tenodesis, which obtained poor clinical satisfaction and more subsequent sprains. (2) Non-anatomic reconstruction abnormally increased inversion stiffness at the subtalar level as compare with anatomic repairment. (3) Multiple types of modified Brostrom procedures could acquire good clinical results. (4) Anatomic reconstruction is a better procedure for some specific patients.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-0870-6) contains supplementary material, which is available to authorized users.

Fracture Through a Distal Fibular Tunnel Used for an Anatomic Lateral Ankle Ligament Reconstruction

Anatomic lateral ankle ligament reconstruction using free tendon graft with osseous tunnels has become a popular technique for revision reconstruction of the lateral ankle ligaments. With the procedure’s burgeoning popularity, an accompanying increase in postoperative complications is likely to occur. We report on one such complication: traumatic distal fibula fracture through the transosseous tunnels.

Non-anatomical or direct anatomical repair of chronic lateral instability of the ankle: A systematic review of the literature after at least 10 years of follow-up

INTRODUCTION

A lateral ankle sprain is one of the most frequent reasons for consultation at the emergency trauma unit. Numerous surgical procedures have been described with long-term outcomes that differ.

HYPOTHESIS

The long-term results of anatomical repair of the anterior talofibular ligament (ATFL) and the calcaneofibular (CFL) ligament are better, with less secondary radiological osteoarthritis than non-anatomical repair.

MATERIALS AND METHODS

A review of the literature after a minimum follow-up of 10 years was performed to analyze the clinical and radiological results of direct anatomical repair (Broström, Duquennoy) and non-anatomical repair (Watson Jones, Evans, Castaing). Thirteen articles were selected.

RESULTS

Eight hundred and one ankles were evaluated after a mean follow-up of 15.3 years. The functional outcome was better after anatomical repair but with recurrent instability. Loss of range of motion and secondary osteoarthritis was more frequent after non-anatomical repair.

CONCLUSION

Anatomical repair of the lateral collateral ligament of the ankle resulted in a better functional outcome and less secondary osteoarthritis than non-anatomical repair.

STUDY DESIGN

Review of the literature; level of proof IV.

Clinical and magnetic resonance imaging assessment of anatomical lateral ankle ligament reconstruction: comparison of tendon allograft and autograft

PURPOSE

To compare the results of anatomical lateral ankle ligament (LAL) reconstruction with tendon allograft and autograft using clinical scores and ultrashort echo time (UTE) sequence of MRI.

METHODS

A total of 26 patients with LAL reconstruction were recruited in this study, including 16 using semitendinosus allografts and 10 using semitendinosus autograft. All of them were diagnosed as chronic ankle instability and accepted anatomic reconstruction. The American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson score, and radiological evaluation using MRI UTE scanning were extracted from each patient. The comparative analysis of the clinical assessments and UTE-T2* values were performed between the patients using autografts and allografts.

RESULTS

For the allograft group, the mean AOFAS score improved from 69.9 ± 13.3 to 94.8 ± 5.4 (P = 0.000), and the mean Karlsson score improved from 70.3 ± 12.2 to 93.8 ± 5.6 (P = 0.000). For the autograft group, the mean AOFAS score improved from 68.4 ± 10.0 to 94.7 ± 5.0 (P = 0.000), and the mean Karlsson score improved from 64.5 ± 14.4 to 95.0 ± 5.8 (P = 0.000). No significant differences were found between the allograft and autograft neither before (AOFAS P = 0.756, Karlsson P = 0.285) nor after (AOFAS P = 0.957, Karlsson P = 0.574) surgery. While the UTE T2* values in allograft were higher than those of autograft group both in anterior talofibular ligament (8.3 ± 1.0 vs 7.6 ± 1.1 P = 0.027) and intra-tunnel graft (7.8 ± 0.6 vs 7.2 ± 0.8 P = 0.045).

CONCLUSION

Both allograft and autograft reconstructions could get an ideal patient satisfaction and clinical functional outcomes at the follow-up. Higher T2* values were found in allograft group which indicated that autograft had some superiorities in respect of revascularization process, collagen structure, water content, and tendon properties.

Hamstring Autograft for Foot and Ankle Applications

BACKGROUND

Hamstring tendon autografts may be used for foot and ankle surgeries, although reports on their effectiveness and morbidity in the foot and ankle literature are limited. We studied a cohort of patients who underwent hamstring harvest for foot and ankle applications, hypothesizing that morbidity to the knee would be limited.

METHODS

We studied a cohort of patients who underwent hamstring autograft for foot or ankle applications by a fellowship-trained sports and foot and ankle surgeon since 2011. Thirty-seven patients underwent isokinetic strength testing using a dynamometer an average of 38 months postoperatively. The average patient age was 45 ± 16 (range, 18-78) years, and 54% were women. Peak flexion and extension torque as well as flexion and extension torque at 30, 70, and 90 degrees of flexion were collected at 2 different testing speeds, 180 and 300 degrees/s. t tests were used for all comparisons.

RESULTS

At follow-up, 32 patients (86%) reported no pain at the harvest site; the remaining 5 patients reported mild to moderate symptoms. No patients were dissatisfied, and all would recommend the surgery to someone else. Flexion strength at higher degrees of flexion was significantly lower compared with extension strength as well as compared with flexion strength at lower degrees of flexion, when testing was performed at lower speed ( P < 0.05).

CONCLUSIONS

When used for foot and ankle surgery, hamstring autografts resulted in high patient satisfaction with minimal donor site morbidity. While knee flexion strength was decreased at higher degrees of flexion, this finding did not appear to be clinically significant.

LEVEL OF EVIDENCE

Level IV, case series.

Revision anatomical reconstruction of the lateral ligaments of the ankle augmented with suture tape for patients with a failed Broström procedure

AIMS

The aim of this prospective study was to evaluate the intermediate-term outcomes after revision anatomical ankle ligament reconstruction augmented with suture tape for a failed modified Broström procedure.

PATIENTS AND METHODS

A total of 30 patients with persistent instability of the ankle after a Broström procedure underwent revision augmented with suture tape. Of these, 24 patients who were followed up for more than two years were included in the study. There were 13 men and 11 women. Their mean age was 31.8 years (23 to 44). The mean follow-up was 38.5 months (24 to 56) The clinical outcome was assessed using the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM) score. The stability of the ankle was assessed using stress radiographs.

RESULTS

The mean FAOS and FAAM scores improved significantly to 87.5 (73 to 94) and 85.1 (70 to 95) points at final follow-up, respectively (p < 0.001). The mean angle of talar tilt and anterior talar translation improved significantly to 2.8° (0° to 6°) and 4.1 mm (2 to 7) at final follow-up, respectively (p < 0.001). Side to side comparison in stress radiographs at final follow-up showed no significant difference. The revision failed in one patient who underwent a further revision using allograft tendon.

CONCLUSION

The revision modified Broström procedure augmented with suture tape is an effective form of treatment for recurrent instability of the ankle following a failed Broström procedure. This technique provides reliable stability and satisfactory clinical outcomes at intermediate-term follow-up. Cite this article: Bone Joint J 2017;99-B:1183-9.

Outcomes of the Modified Broström Procedure Augmented With Suture-Tape for Ankle Instability in Patients With Generalized Ligamentous Laxity

BACKGROUND

Although recent biomechanical studies have reported mechanical superiority of augmented anterior talofibular ligament reconstruction using suture-tape, clinical evidence regarding the efficacy of suture-tape augmentation is still insufficient. This prospective study was performed to evaluate the outcomes of the modified Broström procedure augmented with suture-tape for chronic ankle instability with generalized ligamentous laxity, which has been known to be a poor prognostic factor for anatomic ligament repair.

METHODS

Twenty-eight patients with generalized ligamentous laxity were followed for more than 2 years after the augmented modified Broström procedures for chronic ankle instability. Generalized ligamentous laxity was defined as a Beighton score ≥4 points. The clinical evaluation consisted of the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM) score. Measurement of talar tilt angle and anterior talar translation was obtained from stress radiographs to evaluate mechanical ankle stability.

RESULTS

FAOS and FAAM scores had significantly improved from preoperative average 63.2 and 54.3 points to 90.6 and 89.5 points at final follow-up, respectively ( P < .001). Talar tilt angle and anterior talar translation had significantly improved from preoperative average 16.2° and 12.1 mm to 3.6° and 4.2 mm at final follow-up, respectively ( P < .001). Preoperative side-to-side comparison with stress radiographs was significantly different, but this returned to within nonstatistical differences at final follow-up, respectively ( P = .105, .532). Although 6 patients sustained an ankle sprain after operation, only 1 patient (3.6%) showed a recurrence of subjective and mechanical instability.

CONCLUSIONS

Suture-tape augmentation for the modified Broström procedure appears to be an effective operative alternative for chronic ankle instability with generalized ligamentous laxity. As one of the methods to improve the clinical outcomes in patients with relative contraindications of the modified Broström repair, this procedure provided reliable stability with the advantages of anatomic ligament repair through the augmentation using suture-tape.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Operative treatment of lateral ligament instability

PURPOSE OF REVIEW

Ankle sprains, which account for 40% of sports injuries in the USA, can lead to chronic ankle instability. Chronic ankle instability can be classified as functional, mechanical, or a combination of both and is diagnosed using a combination of a physical exam, an MRI, and stress radiographs. This review focuses on different approaches to treatment, including non-operative and operative techniques, of chronic ankle instability, including reviewing traditional procedures as well as more novel and newer techniques.

RECENT FINDINGS

Based on existing literature, non-operative treatment should always precede operative treatment of chronic ankle instability. If rehabilitation fails, Brostrom-Gould type ankle stabilization has been the preferred surgical option. Recent literature suggests that arthroscopic repair might reduce recovery time and improve outcomes in certain populations; however, there are higher rates of complication following these surgeries. In more high-risk populations, some literature reports that ligament repair with peroneus brevis transfer could be a more effective treatment option. Currently, varying surgical techniques exist for the treatment of chronic ankle instability. While the more recently reported techniques show promise, it is important to note that there is little evidence showing they are more successful than traditional techniques. It is imperative that future studies focus on outcomes and complication rates of these newer procedures.

Donor Site Morbidity After Lateral Ankle Ligament Reconstruction Using the Anterior Half of the Peroneus Longus Tendon Autograft

BACKGROUND

The anterior half of the peroneus longus tendon (AHPLT) has been reported to be an effective autograft for ligament reconstruction with respect to strength and safety. However, there is little information regarding donor site morbidity after harvesting the AHPLT. Furthermore, to the best of our knowledge, there has not been a study on the isokinetic evaluation of ankle plantar flexion and eversion after AHPLT harvesting.

PURPOSE

To evaluate the clinical and radiographic results after lateral ankle ligament reconstruction using the AHPLT. We further investigated whether harvesting the AHPLT for lateral ankle ligament reconstruction decreases the strength of ankle plantar flexion and eversion.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty consecutive patients (31 cases) were treated by anatomic lateral ligament reconstruction using the AHPLT. For the clinical assessment, visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS), and Karlsson-Peterson scores were evaluated preoperatively and at the last follow-up. For the radiographic assessment, talar tilt angle and anterior talar displacement were measured preoperatively and at the last follow-up. The peak isokinetic torques for ankle plantar flexion at angular velocities of 30 and 120 deg/s and eversion at angular velocities of 30 and 60 deg/s were measured at a minimum of 1 year after surgery.

RESULTS

The mean VAS score improved significantly from 6.4 ± 1.7 preoperatively to 1.6 ± 1.5 at the last follow-up ( P < .001). The mean respective AOFAS and Karlsson-Peterson scores improved significantly from 57.2 ± 12.8 and 66.9 ± 13.6 preoperatively to 89.0 ± 10.0 and 93.3 ± 5.7 at the last follow-up ( P < .001). The mean talar tilt angle improved significantly from 15.3° ± 6.2° preoperatively to 3.4° ± 3.0° at the last follow-up ( P < .001), and the mean anterior talar displacement improved significantly from 10.2 ± 3.3 mm preoperatively to 6.3 ± 1.9 mm at the last follow-up ( P < .001). No significant differences were observed between the uninvolved and involved legs in the mean peak torque for plantar flexion at angular speeds of 30 deg/s ( P = .517) and 120 deg/s ( P = .347) or for eversion at angular speeds of 30 deg/s ( P = .913) and 60 deg/s ( P = .983).

CONCLUSION

Anatomic lateral ligament reconstruction using the AHPLT showed good clinical and radiographic results without a significant decrease in the peroneus longus strength. Lateral ligament reconstruction using the AHPLT may be a good surgical option for the treatment of chronic ankle instability.

Modified Broström Procedure for Chronic Ankle Instability With Generalized Joint Hypermobility

BACKGROUND

Chronic ankle instability with generalized joint hypermobility (GJH) is considered a contraindication for the modified Broström procedure. The most widely accepted definition of GJH is a Beighton score of ≥4 on a 9-point scale. However, it is not clear whether this criterion can be applied to determine the GJH that would lead to a poor outcome after a modified Broström procedure. Some of the previous studies that report unfavorable outcomes do not specify the tests or cutoff scores used to determine the GJH, and, in fact, some of the patients with GJH in these studies had good outcomes.

HYPOTHESIS

The modified Broström procedure results in satisfactory outcomes in patients who have chronic ankle instability with GJH if the contralateral uninjured ankle shows a normal varus talar tilt and anterior talar translation during stress tests.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Modified Broström procedure was performed in 32 patients with chronic ankle instability with GJH if the contralateral uninjured ankle showed a normal varus talar tilt and anterior talar translation on stress tests. The mean patient age at surgery was 21.7 years, and the mean follow-up duration was 27.4 months.

RESULTS

The Karlsson-Peterson ankle score significantly improved from a mean ± SD of 63.6 ± 7.1 preoperatively to 90.4 ± 6.7 at the final postoperative follow-up (P < .001). Sixteen patients were very satisfied with the results, 10 patients were satisfied, 3 patients rated their satisfaction as fair, and 1 patient was dissatisfied with the results. Nine patients sustained ankle sprains after the surgery, 6 of which were mild sprains. Although 3 of these 9 patients had a mechanically unstable ankle on stress radiographs, they were satisfied with the postoperative results. None of the patients required a reoperation.

CONCLUSION

GJH was not a contraindication for the modified Broström procedure if the contralateral uninjured ankle showed a normal varus talar tilt and a normal anterior talar translation on stress tests. Further studies are needed to better define GJH affecting the ankle.

Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon

PURPOSE

The purpose of this study was to assess the results of a novel surgical technique for the treatment of chronic lateral ankle instability with attenuated or deficient ligamentous tissue that the modified Broström procedure could not be performed. A lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon has been performed.

METHODS

Thirty-four consecutive patients treated with lateral ankle ligament reconstruction using anterior half of the peroneus longus tendon were enrolled. Median age at surgery was 24 years (range 19-46 years). The clinical and radiologic outcomes were evaluated preoperatively and at a median of 21 months (range 12-51 months) follow-up.

RESULTS

The Karlsson-Peterson ankle score significantly improved from 58.2 ± 10.9 points preoperatively to 83.9 ± 7.0 points at the last follow-up. Mechanical stability was achieved. The mean talar tilt angle significantly improved from 15.7° ± 3.5° preoperatively to 4.6° ± 1.7° at the last follow-up, and the mean anterior talar translation significantly improved from 7.3 ± 2.6 mm preoperatively to 4.1 ± 1.7 mm at the last follow-up. Fifteen patients (52%) were very satisfied with the results, nine patients (31%) were satisfied, four patients (14%) were fair, and one patient (3%) was dissatisfied with the results.

CONCLUSIONS

Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon can be a surgical option for chronic lateral ankle instability with attenuated or deficient ligaments.

LEVEL OF EVIDENCE

Case-series, Level IV.

Accelerated Versus Traditional Rehabilitation After Anterior Talofibular Ligament Reconstruction for Chronic Lateral Instability of the Ankle in Athletes

BACKGROUND

Although several reconstruction procedures for chronic lateral ankle instability using autografts have been reported, all have recommended postoperative immobilization and a nonweightbearing period.

HYPOTHESIS

Reconstructive surgery with a gracilis autograft using an interference fit anchoring system for chronic lateral ankle instability enables early accelerated rehabilitation and recovery with a return to activity without requiring immobilization.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 33 patients (33 feet) who underwent reconstruction of the anterior talofibular ligament with a gracilis autograft using interference screws were included; 15 were followed for 4 weeks with postoperative cast immobilization (group I), while 18 were followed with accelerated rehabilitation without immobilization (group A). Clinical and radiological results were evaluated based on the Karlsson and Peterson score, talar tilt angle, anterior displacement of the talus on stress radiography, and time between surgery and return to full athletic activity.

RESULTS

The mean Karlsson and Peterson scores before and 2 years after surgery were the following: for group I: 62.3 ± 4.7 (range, 54-72) and 94.4 ± 7.1 (range, 76-100), respectively (P < .001), and for group A: 64.1 ± 4.8 (range, 57-70) and 91.7 ± 7.7 (range, 74-100), respectively (P < .001). The mean difference in the talar tilt angle compared with the contralateral side and mean displacement of the talus on stress radiography before and 2 years after surgery were the following: for group I: 8.7° ± 2.6° and 7.7 ± 1.8 mm and 3.8° ± 1.5° and 4.0 ± 1.6 mm, respectively, and for group A: 10.5° ± 3.4° and 8.7 ± 2.1 mm and 4.3° ± 1.8° and 4.3 ± 1.2 mm, respectively. Radiography revealed significantly improved postoperative outcomes in both groups (P < .0001). No significant differences in the score and any parameters on stress radiography were evident at 2 years after surgery between the groups. The mean time between surgery and return to full athletic activity was significantly higher in group I (18.5 ± 3.5 weeks) than in group A (13.4 ± 2.2 weeks) (P < .0001). No cases of reinjury were reported, and no differences in athletic performance ability were observed between the groups.

CONCLUSION

Patients in group A returned to full athletic activity 5 weeks earlier than those in group I, demonstrating the advantage of accelerated rehabilitation after surgery.

Anterior talofibular ligament ruptures, part 2: biomechanical comparison of anterior talofibular ligament reconstruction using semitendinosus allografts with the intact ligament

BACKGROUND

Anatomic reconstructions of the lateral ankle ligaments with grafts have been proposed for patients with generalized ligamentous laxity, long-standing instability with attenuated native tissues, varus hindfoot misalignment, or failed prior lateral ligament surgery and for very large patients or elite athletes because of increased demands.

HYPOTHESIS

Anatomic reconstruction of the anterior talofibular ligament (ATFL) using a semitendinosus allograft fixed with biocomposite interference fit screws would have similar biomechanical properties to the intact ATFL at time zero in a cadaveric model.

STUDY DESIGN

Controlled laboratory study.

METHODS

Allograft reconstruction of the ATFL was performed in 6 fresh-frozen cadaveric ankles. The specimens were loaded to failure to determine the strength and stiffness of the reconstruction and compared with data from 6 cadaveric specimens with intact ATFLs.

RESULTS

The mean ultimate load to failure of the allograft reconstruction (170.7 ± 54.8 N) was not significantly different from that of the intact ATFL (154.0 ± 63.7 N). The mean stiffness of the allograft reconstruction (23.1 ± 9.3 N/mm) was also not significantly different from that of the intact ATFL (14.5 ± 4.4 N/mm).

CONCLUSION

Anatomic reconstruction of the ATFL with allografts demonstrated similar strength and stiffness to the native ligament at time zero in a fresh-frozen cadaveric model.

CLINICAL RELEVANCE

This technique of anatomic reconstruction of the ATFL with allografts has biomechanical validation for use in clinical situations where a Broström repair of the lateral ankle ligaments is unlikely to be successful or has previously failed.

Near-anatomic allograft tenodesis of chronic lateral ankle instability

BACKGROUND

Current operative treatment options for chronic lateral ankle instability include anatomic repairs utilizing existing local tissue and nonanatomic reconstructions sacrificing the peroneus brevis tendon to mechanically stabilize the ankle. Recent studies have modified these techniques to create an anatomic reconstruction utilizing allograft tendons. The purpose of this study was to retrospectively examine the clinical outcomes of a near-anatomic ligament reconstruction utilizing an allograft tendon for recurrent or complex lateral ankle instability.

METHODS

Twenty-eight patients underwent a near-anatomic allograft lateral ankle ligament reconstruction with a semitendinosis allograft for severe or recurrent lateral ankle ligamentous instability, and all of them were available for follow-up at an average 32 months. Twelve patients had previously undergone lateral ankle ligament stabilizing surgery, 4 had Ehlers Danlos syndrome with poor local tissue, 5 had greater than 30 degrees of varus angulation of talar tilt, while 12 had associated hindfoot varus requiring concomitant reconstruction. Patients were assessed pre- and postoperatively for Visual Analog Scores (VAS) for pain, Foot and Ankle Ability Measures (FAAM), patient satisfaction, radiographic correction, and complications.

RESULTS

Median VAS of pain decreased from 8 before surgery to 1 after surgery (P < .001). Median FAAM score increased from 41.7 to 95.2 after surgery (P < .001). Radiographic comparison demonstrated correction of preoperative varus malalignment in all but 1 patient. No patients developed subsequent subtalar arthritis or pain. Three patients had mild persistent instability, all of which was managed nonoperatively. One of the patients with persistent instability also developed chronic regional pain syndrome following surgery. At final follow-up, 25 of 28 patients rated their satisfaction as good or excellent and 3 as fair. No patients required revision surgery.

CONCLUSION

Lateral ligament reconstruction utilizing a near-anatomically placed and tensioned allograft tendon was a viable option in treating recurrent and complex lateral instability. Not sacrificing the peroneal tendons avoided loss of eversion strength. Near-anatomic placement of the allograft provided good ankle stability without sacrificing subtalar motion or predisposition to subtalar arthritis in short-term follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Autologous split peroneus longus lateral ankle stabilization

Lateral ankle instability is a common clinical entity, and a variety of surgical procedures are available for stabilization after conservative management fails. Herein the authors reviewed outcomes after performing autologous split peroneus longus lateral ankle stabilization, using a previously described surgical technique to anatomically recreate the anterior talofibular and calcaneofibular ligaments. Twenty-five consecutive patients from 2 surgeons' practices underwent reconstruction between March 2007 and January 2011 with a minimum follow-up of 12 (range 12 to 51) months (mean 29.5 months). Follow-up interviews demonstrated 92.0% good or excellent outcomes with only 8.0% rating the outcome as fair and none as poor; 92.0% had no recurrent sprains or difficulty going up or down hills; 88.0% related no difficulty with uneven ground. The authors conclude that the autologous split peroneus longus lateral ankle stabilization results in a stable ankle with a low rate of complications and high patient satisfaction.

Results of anatomic lateral ankle ligament reconstruction with tendon allograft

Chronic ankle instability can be addressed surgically through direct lateral ligament repair, non-anatomic reconstruction, or anatomic reconstruction. The goal of this study was to assess the radiographic, functional, and clinical results of patients undergoing an anatomic lateral ankle ligament reconstruction using an anterior tibial tendon allograft. Eleven patients (12 feet; mean age, 48.9 ± 11.4 years) undergoing lateral ankle ligament reconstruction were followed at a mean of 3.5 ± 1.7 years after surgery (range, 1.2 to 5.0 years). Indications for surgery were previous failed repair (i.e., Broström; one case), hyperlaxity (seven cases), and high-demand patients (four cases). Subjective outcomes including the Foot and Ankle Outcome Score (FAOS), SF-36, and activity level were assessed. Mortise and lateral ankle stress radiographs were performed. The FAOS daily activity and sports activity subscores were 93.4 (range, 77.9 to 100) and 78.6 (range, 30 to 100), respectively. The SF-36v2 physical health and mental health components were 50.4 (range, 30.6 to 65.7) and 45.0 (range, 24.8 to 68.0), respectively. Four patients (five feet) reported no restriction; six patients reported mild restrictions, and one patient reported moderate activity restrictions. Tibiotalar tilt improved significantly from 20.2° to 4.6° after surgery (p < 0.01). The radiographic anterior displacement of the talus from the tibia was 6.5 mm postoperatively. The technique described restores mechanical stability in patients with chronic lateral ankle instability and may be considered in a select group of patients.

Deltoid ligament reconstruction with peroneus longus autograft in flatfoot deformity

BACKGROUND

Stage IV posterior tibial tendon insufficiency is characterized by the presence of valgus talar tilt in the setting of a flatfoot deformity which results from attenuation of the deltoid ligament. Correcting valgus tilt at the time of flatfoot reconstruction may prevent future collapse and the need for joint sacrificing procedures. The purpose of this study was to report the intermediate-term results of patients who underwent deltoid ligament reconstruction using a peroneus longus tendon transfer.

MATERIALS AND METHODS

Five patients (mean age, 67 years ± 5.3 years) who underwent flatfoot reconstruction along with deltoid ligament reconstruction using a peroneus longus autograft were evaluated at a mean of 8.9 ± 1.7 years after surgery. The FAOS, SF-36v2, and VAS surveys were administered. The correction of valgus talar tilt was determined with weightbearing radiographs of the ankle. Ankle range of motion along with standing hindfoot alignment was assessed.

RESULTS

The postoperative average FAOS and SF-36v2 were 68.3 (range, 55.2 to 85.0) and 75.7 (range, 40 to 92), respectively. The valgus talar tilt improved from 7.7 degrees preoperatively to 2.1 degrees postoperatively. Mean ankle range of motion was 47 degrees (range, 40 degrees to 55 degrees). Mean hindfoot alignment was 4 degrees valgus (range, 1 degree varus to 8 degrees valgus).

CONCLUSION

Deltoid ligament reconstruction using a peroneus longus tendon transfer was a useful technique for reducing tibiotalar tilt in the setting of stage IV flatfoot deformity. Correction and function were maintained at intermediate-term followup.

Management of acute and chronic ankle instability

Acute lateral ankle ligament injuries are common. If left untreated, they can result in chronic instability. Nonsurgical measures, including functional rehabilitation, are the management methods of choice for acute injuries, with surgical intervention reserved for high-demand athletes. Chronic lateral ankle instability is multifactorial. Failed nonsurgical management after appropriate rehabilitation is an indication for surgery. Of the many surgical options available, anatomic repair of the anterior talofibular and calcaneofibular ligaments is recommended when the quality of the ruptured ligaments permits. Anatomic reconstruction with autograft or allograft should be performed when the ruptured ligaments are attenuated. Ankle arthroscopy is an important adjunct to ligamentous repair and should be performed at the time of repair to identify and address intra-articular conditions associated with chronic ankle instability. Tenodesis procedures are not recommended because they may disturb ankle and hindfoot biomechanics.