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An Anatomic and Autologous Lateral Ankle Stabilization
An Anatomic and Autologous Lateral Ankle Stabilization John M. Schuberth, DPM,1 Paul R. Smith, DPM,2 and Meagan M. Jennings, DPM3 A new technique for stabilization of the lateral ankle ligaments is presented. The procedure uses a split peroneus longus tendon to recreate the calcaneofibular and anterior talofibular ligaments. The new ligaments follow a precise anatomic course that replicates the pathway of the original ligaments. The procedure also capitalizes on interference screw technology so that accurate ligament tension can be obtained. This technique is most useful for severe ligamentous insufficiency involving both the calcaneofibular and anterior talofibular ligaments. Biomechanical rationale for the use of peroneus longus is also discussed. (The Journal of Foot & Ankle Surgery 48(6):700–705, 2009) Key Words: ankle instability, autologous tendon graft, interference screw, lateral ankle stabilization, peroneus longus
Numerous stabilization techniques of the lateral ankle ligaments, most commonly the anterior talofibular (ATF) and calcaneofibular (CF), have been described including either primary repair or secondary repair using tenodesis techniques. Multiple techniques have been described for tenodesis repair, both anatomic and nonanatomic, as well as single- (ATF) versus double- (ATF and CF) ligament repairs. Nonanatomic, single-ligament and double-ligament repairs have been described most commonly using the peroneus brevis (PB) tendon (1–4); however, sacrifice of the primary everter of the foot and ankle and nonanatomic configurations have been shown to have suboptimal effects on the ankle joint, including limitation of subtalar motion and reduction of eversion strength (5–8). The authors describe a technique in which a split peroneus longus (PL) constrained autologous tendon graft is used to perform an anatomic reconstruction of the ATF and CF ligaments in lateral ligament instability. The benefits of this procedure include maintenance of the PB, anatomical configuration of the ligaments, the use of autogenous graft material, and the ability to optimize graft tension.
Address correspondence to: John M. Schuberth, DPM, Chief, Foot and Ankle Surgery, Department of Orthopedic Surgery, Kaiser Foundation Hospital, 450 6th Avenue. San Francisco, CA 94118. E-mail: Jmfoot@aol. com. 1 Chief, Foot and Ankle Surgery, Department of Orthopedic Surgery, Kaiser Foundation Hospital, San Francisco, CA. 2 Private Practice, Gifford Medical Center, Randolph, VT. 3 Staff Surgeon, Orthopedics and Podiatry Department, Camino Medical Division, Palo Alto Medical Foundation, Mountain View, CA. Financial Disclosure: None reported. Conflict of Interest: None reported. Copyright Ó 2009 by the American College of Foot and Ankle Surgeons 1067-2516/09/4806-0020$36.00/0 doi:10.1053/j.jfas.2009.07.006
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Surgical Technique The patient is placed in a lateral decubitus position on a bean bag or other suitable support so that the operated leg is most superior. All bony prominences are appropriately padded, and a bump is used to support the medial side of the involved extremity (Figure 1). The first incision is made over the junction of the middle and distal third of the fibula, approximately 3 cm in length. The fascial layer is exposed and the lateral compartment is entered with a longitudinal incision. The peroneus longus muscle tendon unit is captured with a blunt instrument (Figure 2, A). A second incision is made at the inferior aspect of the lateral malleolus directly over the peroneal tendon sheath and extends over the lateral aspect of the calcaneus. The peroneal sheath is incised longitudinally, distal to the superior peroneal retinaculum, and the peroneus longus tendon is delivered. A stab incision is made in a longitudinal fashion just distal to the tip of the fibula, dividing the tendon into an anterior and posterior portion (Figure 2, B). Umbilical tape or Fiberwire (Arthrex, Naples, FL) is placed around the posterior most half of the peroneus longus (Figure 2, C). Two strands of either material are placed. A uterine packing forceps or other suitable long instrument is inserted into the superior most incision, into the peroneal sheath and advanced distally to exit the inferior incision. The tip of the forceps should be visible within the peroneal sheath distally (Figure 2, C and D). The tips of the forceps are spread with a thin instrument and the ends of one of the strands of umbilical tape or Fiberwire are placed in the jaws. The forceps are withdrawn from the superior incision along with the tips of the umbilical tape (Figure 2, E). The material is secured and then firmly pulled proximally, thereby splitting the peroneus longus into a posterior and anterior portion. The posterior limb of the tendon is transected in the proximal wound
FIGURE 1 Superior view of leg position for lateral ankle stabilization. The lateral border of the foot is essentially parallel to the floor. The proposed incisions have been delineated.
heel is held in maximal eversion and neutral ankle flexion by resting the medial surface of the foot on a bump. Substitution of the anterior talofibular ligament is facilitated by the remaining exposed portion of the peroneal tendon. The neck of the talus is exposed through a separate exposure and the natural insertion point of the ATF ligament is identified. A second channel for a second biotenodesis screw is created at that point with the same drill–guide wire technique (Figure 5, A). However the drill is not passed completely through the talus; rather, a 20-mm-deep channel is made. The foot is externally rotated and pushed posteriorly to minimize the distance between the anterior ridge of the fibula and the talar neck. The ligament is tensioned as well and secured with a second biotenodesis screw (Figure 5, B and C). Closure is performed in layers and the leg is placed in a short-leg splint or cast with the heel everted and the ankle at neutral. Postoperative Regimen
and then retracted from the distal wound with the second strand of suture material (Figure 2, F). Two converging 3.5-mm drill holes are made in the lateral aspect of the calcaneus in line with the natural course of the peroneus longus. The posterior-most hole should be just inferior to the calcaneal tubercle (Figure 3, A). A suture loop is then used to pass the free posterior limb of the peroneus longus from anterior to posterior through the osseous channel (Figure 3, A). A hemostat is used to create a corridor from the tip of the fibula to the drill hole, but must pass deep to the peroneal sheath (Figure 3, B). The anterior aspect of the fibula and lateral talofibular facet is exposed with a vertical incision centered over the lateral gutter. The channel for passage of the tendon-ligament graft is made in the distal fibula with a cannulated drill over a guide pin. Most commonly a 4.75-mm caliber biotenodesis screw is used. As such, a 5.5-mm drill is selected. The guide wire is placed at the tip of the fibula and directed toward the anterior ridge of the malleolus, corresponding to the point of attachment of the calcaneofibular ligament inferiorly and the anterior talofibular ligament superiorly (Figure 4, A). It is critical that the guide wire be centered within the cubic content of the lateral malleolus so as not to penetrate the fibular-talar facet (Figure 4, B). In addition, the instruments should be lavaged with saline to dissipate heat during the drilling process. A suture loop is then used to pass the peroneal tendon limb from the tip of the fibula to the anterior ridge of the fibula (Figure 4, C). Prior to passage, the peroneal tendon limb is passed deep to the peroneal tendon sheath to simulate the course of the calcaneofibular ligament. Once the tendon limb has been passed the heel is maximally everted and the tendon-ligament is tensioned. The tension from the calcaneus to the tip of the fibula is fixed with insertion of the biotendesis screw (Figure 4, D). For the duration of the procedure the
The patient is seen at the usual postoperative interval for suture removal and the extremity is placed in a short-leg cast with the heel fully everted and the ankle at neutral to protect the repaired ligaments. At 4 weeks postoperative, a neutral short-leg walking cast is applied. A removable cast boot is used at 6 weeks postoperative for an additional 2 weeks, followed by a physical therapy program comparable to any other lateral ankle stabilization protocol. Full sports activity is allowed at 12 weeks postoperatively. Discussion Ankle instability is a disabling condition that can be addressed by primary or secondary repair of the ATF and/or CFL ligaments. When reconstructing the lateral ankle ligaments, one must consider the goals of the procedure, restoring anatomic configuration, and encouraging a synergistic stabilization between the dynamic tendons and static ligaments. Studies comparing primary repair, anatomical tenodesis, and nonanatomical tenodesis have shown that an anatomical configuration provides a closer restoration of normal joint kinematics and pressures (9–13). The technique described herein has some distinct advantages compared with alternative ankle stabilization procedures. Most importantly it provides for reconstruction of both the calcaneofibular and anterior talofibular ligaments. Although good results have been reported for the Brostrom-type procedures in managing ankle instability, it is unclear whether the patients in these series had 2-ligament insufficiency (14–17). Moreover, there is a leap of faith to expect that plication of the residual ligament tissue adequately stabilizes the ankle. Furthermore, some patients may have insufficient integrity of the local tissue cuff, or
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FIGURE 2 (A) Intraoperative photograph showing the capture of the peroneus longus tendon in the proximal incision. The distal incision allows for longitudinal splitting of the peroneus longus tendon. (B) Close-up of tendon splitting. (C) Split peroneus longus tendon with 2 umbilical tapes looped around the posterior component of the divided tendon. The tips of the uterine packing forceps are visible within the sheath. (D) Wider view showing the placement of the forceps in preparation for tendon splitting. (E) Peroneus longus tendon has been split by retracting one of the umbilical tape loops proximally. The second loop is used distally for counter-traction. (F) Posterior limb has been transected in the proximal incision and withdrawn through the distal limb.
FIGURE 3 (A) Lateral view of the foot showing the 2 converging drill holes to create a bony tunnel in the lateral wall of the calcaneus. A suture loop is placed through the tunnel to pass the tendon from anterior to posterior through the tunnel. (B) Intraoperative photo showing development of channel for passage of the graft from the posterior calcaneal hole to the tip of the fibula. The corridor is created deep to the peroneal tendon complex, to replicate the course of the calcaneofibular ligament.
concomitant subtalar instability to preclude the use of ‘‘in situ’’ repairs (18). Anatomic repair of the insufficient ligaments is appealing because the insertion points of each ligament are restored. In turn, the normal kinematics of the affected joints, the ankle and subtalar, are maintained. This may be important, as the ankle and hindfoot complex is stressed through the entire range of motion during vigorous physical activity. Furthermore, the restoration of both of the affected ligaments in 702
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anatomic fashion eliminates the possibility of subtle or overt restriction of supinatory motion of the ankle that occurs in nonanatomic configurations (16). These changes include inhibition of hindfoot range of motion, loss of long-term stability, and medial degenerative changes (16). In effect, less satisfactory results are realized. The use of split peroneus longus (PL) tendon has been previously described for lateral ankle ligament reconstruction (19). The use of this structure is less biomechanically
FIGURE 4 (A) Insertion of the guide pin for creation of osseous channel in the distal fibula. The insertion point is the tip of the fibula to correspond to the anchor point of the calceaneofibular ligament. (B) Wider view showing the entrance and exit points of the guide wire. The wire exits the anterior ridge of the fibula to correspond to the attachment of the anterior talofibular ligament. (C) Suture loop placed from anterior to posterior through the osseous channel in the fibula. The loop passes deep to the peroneal tendons. In this case, the distal exposure was achieved through a single incision, as was done early in the development of the technique. (D) Intraoperative view showing the anchoring of the new calcaneofibular ligament to the distal fibula. Note that the heel is maximally everted by placing the medial aspect of the calcaneus, thereby elevating the extremity off of the operating table. The assistant applies traction to the tendon graft as the biotenodesis screw is inserted.
detrimental, as the PL tendon’s main function is to stabilize the first ray and the medial column, which may encourage hindfoot inversion (20). Therefore, the assumed loss of some power will reduce the supinatory thrust on the hindfoot complex and dampen the tendency for an inversion injury. Although there have been a number of methods proposed using the PB tendon, reduction of eversion strength has been demonstrated by almost 10% in the Evans and Chrisman-Snook procedures (1–4, 8). Although the PB can also be used in the technique herein, it makes little sense to potentially weaken an important everter and lateral stabilizing force of the lateral ankle and hindfoot. Furthermore, from a technical standpoint, the splitting of PB is often complicated by a shorter tendon and an enhanced muscle mass distally. Surgeons may find that the tendon length is insufficient for the obligate pathway of the reconstructed ligaments. The use of autologous tissue is also a distinct advantage for several reasons. First, allograft materials have a proclivity for soft tissue ‘‘creep’’ in that the new ligament will elongate with cyclical load. When autologous tissue is used, the propensity for soft tissue creep is determined by the prior load on the structure. As such, immediate harvest of autologous tissue strongly diminishes the potential to stretch out when placed in a new location under physiologic tension. Although soft tissue creep of an allograft can be mitigated
somewhat with pretensioning of the ligament, this takes additional time in the operating room and has not been shown conclusively to duplicate preharvest loads (21). Furthermore, the small but finite risk of disease transmission or increased risk of infection is eliminated. The capacity to harvest local autologous tissue is even more appealing because additional exposures at distant sites are avoided (22). Last, the use of allograft material adds to the overall cost of the operation. The use of interference screw technology allows the surgeon to modulate the tension of each ligament independently. This is advantageous because isometric tension of each ligament can be realized. It is important that ligaments are taut during the end of normal excursion of the respective joint it stabilizes. With this capability, the excursion can be tested intraoperatively and the ideal end point of calcaneal eversion can be fixed with placement of the first interference screw through the fibula. Anterior displacement of the talus occurs at the expense of rotation about an intact deltoid hinge and this can also be ‘‘dialed in’’ during the surgical procedure. One of the disadvantages of this stabilization procedure as well as all others is that the modulation of ligament tension cannot be quantitated. Yet a qualitative determinant of individual ligament tension is preferable to a global tightening of the entire soft tissue cuff on the lateral side of the ankle.
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FIGURE 5 (A) Intraoperative view of the anterior exposure. The lateral process of the talus is in full view and the guide pin for the biotenodesis screw is placed just anterior to correspond to the attachment of the anterior talofibular ligament. (B) The peroneus longus tendon graft is placed through the fibular tunnel and pulled anteriorly. Note the increased wrinkles in the skin resulting from external rotation and posterior displacement of the talus in the mortise. (C) Placement of the second biotenodesis screw over the guide pin. The final tension of the new anterior talofibular ligament is created just before seating of the biotenodesis screw with the talus in the external and posterior posture in the mortise.
References 1. Evans DL. Recurrent instability of the ankle. Proc R Soc Med 46: 343–344, 1953. 2. Watson-Jones R. Fractures and other bone and joint injuries. In Fractures and Other Bone and Joint Injuries, p 416, E & S Livingstone, Edinburgh, 1940. 3. Nilsonne H. Making a new ligament in the ankle. J Bone Joint Surg 14: 380, 1932. 4. Chrisman OD, Snook GA. Reconstruction of lateral ligament tears of the ankle. An experimental study and clinical evaluation of seven patients treated by a new modification of the Elmslie procedure. J Bone Joint Surg 51A:904–912, 1969. 5. Paterson R, Cohen B, Taylor D, Bourne A, Black J. Reconstruction of the lateral ligaments of the ankle using semi-tendinosis graft. Foot Ankle Int 21:413–419, 2000. 6. Marsh JS, Daigneault JP, Polzhofer GK. Treatment of ankle instability in children and adolescents with a modified Chrisman-Snook repair:
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7. 8.
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a clinical and patient-based outcome study. J Pediatr Orthop 26(1): 94–99, 2006. Sammarco VJ. Complications of lateral ankle ligament reconstruction. Clin Orthop Relat Res 391:123–132, 2001. St Pierre RK, Andrews L, Allman F Jr, Fleming LL. The Cybex II evaluation of lateral ankle ligamentous reconstructions. Am J Sports Med 12:52–56, 1984. Schmidt R, Benesch S, Friemert B, Herbst A, Claes L, Gerngross H. Anatomical repair of lateral ligaments in patients with chronic ankle instability. Knee Surg Sports Traumatol Arthrosc 13:231–237, 2007. Schmidt R, Cordier E, Bertsch C, Eils E, Neller S, Benesch S, Herbst A, Rosenbaum D, Claes L. Reconstruction of the lateral ligaments: do the anatomical procedures restore physiologic ankle kinematics? Foot Ankle Int 25:31–36, 2004. Rosenbaum D, Bertsch C, Claes LE. Tenodeses do not fully restore ankle joint loading characteristics: a biomechanical in vitro investigation in the hind foot. Clin Biomech 12:202–209, 1997. Rosenbaum D, Becker HP, Wilke HJ, Claes LE. Tenodeses destroy the kinematic coupling of the ankle joint complex. A three-dimensional in
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vitro analysis of joint movement. J Bone Joint Surg 80B:162–168, 1998. Rosenbaum D, Becker HP, Sterk J, Gerngross H, Claes L. Functional evaluation of the 10-year outcome after modified Evans repair for chronic ankle instability. Foot Ankle Int 18:765–771, 1997. Li X, Killie H, Guerrero P, Busconi BD. Anatomical reconstruction for chronic lateral ankle instability in teh high-demand athlete: functional outcomes after the modified Brostrom repair using suture anchors. Am J Sports Med 37:488–494, 2009. Krips R, van Dijk CN, Halasi T, Lehtonen H, Moyen B, Lanzetta A, Farkas T, Karlsson J. Anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a 2- to 10-year follow-up, multicenter study. Knee Surg Sports Traumatol Arthrosc 8:173–179, 2000. Krips R, van Dijk CN, Halasi PT, Lehtonen H, Corradini C, Moyen B, Karlsson J. Long-term outcome of anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a multicenter study. Foot Ankle Int 22:415–421, 2001. Krips R, Brandsson S, Swensson C, van Dijk CN, Karlsson J. Anatomical reconstruction and Evans tenodesis of the lateral ligaments of the
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ankle. Clinical and radiological findings after follow-up for 15 to 30 years. J Bone Joint Surg 84B:232–236, 2002. Schmidt R, Cordier E, Bertsch C, Eils E, Neller S, Benesch S, Herbst A, Rosenbaum D, Claes L. Reconstruction of the lateral ligaments: do the anatomical procedures restore physiologic ankle kinematics? Foot Ankle Int 25:31–36, 2004. Bohnsack M, Su¨rie B, Kirsch IL, Wu¨lker N. Biomechanical properties of commonly used autogenous transplants in the surgical treatment of chronic lateral ankle instability. Foot Ankle Int 23:661–664, 2002. Johnson CH, Christensen JC. Biomechanics of the first ray. Part I. The effects of peroneus longus function: a three-dimensional kinematic study on a cadaver model. J Foot Ankle Surg 38:313–321, 1999. Nurmi JT, Kannus P, Sieva¨nen H, Ja¨rvela¨ T, Ja¨rvinen M, Ja¨rvinen TL. Interference screw fixation of soft tissue grafts in anterior cruciate ligament reconstruction: part 2: effect of preconditioning on graft tension during and after screw insertion. Am J Sports Med 32:418–424, 2004. Takao M, Oae K, Uchio Y, Ochi M, Yamamoto H. Anatomical reconstruction of the lateral ligaments of the ankle with a gracilis autograft: a new technique using interference fit anchoring system. Am J Sports Med 33:814–823, 2005.
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Numerous stabilization techniques of the lateral ankle ligaments, most commonly the anterior talofibular (ATF) and calcaneofibular (CF), have been described including either primary repair or secondary repair using tenodesis techniques. Multiple techniques have been described for tenodesis repair, both anatomic and nonanatomic, as well as single- (ATF) versus double- (ATF and CF) ligament repairs. Nonanatomic, single-ligament and double-ligament repairs have been described most commonly using the peroneus brevis (PB) tendon (1–4); however, sacrifice of the primary everter of the foot and ankle and nonanatomic configurations have been shown to have suboptimal effects on the ankle joint, including limitation of subtalar motion and reduction of eversion strength (5–8). The authors describe a technique in which a split peroneus longus (PL) constrained autologous tendon graft is used to perform an anatomic reconstruction of the ATF and CF ligaments in lateral ligament instability. The benefits of this procedure include maintenance of the PB, anatomical configuration of the ligaments, the use of autogenous graft material, and the ability to optimize graft tension.
Address correspondence to: John M. Schuberth, DPM, Chief, Foot and Ankle Surgery, Department of Orthopedic Surgery, Kaiser Foundation Hospital, 450 6th Avenue. San Francisco, CA 94118. E-mail: Jmfoot@aol. com. 1 Chief, Foot and Ankle Surgery, Department of Orthopedic Surgery, Kaiser Foundation Hospital, San Francisco, CA. 2 Private Practice, Gifford Medical Center, Randolph, VT. 3 Staff Surgeon, Orthopedics and Podiatry Department, Camino Medical Division, Palo Alto Medical Foundation, Mountain View, CA. Financial Disclosure: None reported. Conflict of Interest: None reported. Copyright Ó 2009 by the American College of Foot and Ankle Surgeons 1067-2516/09/4806-0020$36.00/0 doi:10.1053/j.jfas.2009.07.006
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Surgical Technique The patient is placed in a lateral decubitus position on a bean bag or other suitable support so that the operated leg is most superior. All bony prominences are appropriately padded, and a bump is used to support the medial side of the involved extremity (Figure 1). The first incision is made over the junction of the middle and distal third of the fibula, approximately 3 cm in length. The fascial layer is exposed and the lateral compartment is entered with a longitudinal incision. The peroneus longus muscle tendon unit is captured with a blunt instrument (Figure 2, A). A second incision is made at the inferior aspect of the lateral malleolus directly over the peroneal tendon sheath and extends over the lateral aspect of the calcaneus. The peroneal sheath is incised longitudinally, distal to the superior peroneal retinaculum, and the peroneus longus tendon is delivered. A stab incision is made in a longitudinal fashion just distal to the tip of the fibula, dividing the tendon into an anterior and posterior portion (Figure 2, B). Umbilical tape or Fiberwire (Arthrex, Naples, FL) is placed around the posterior most half of the peroneus longus (Figure 2, C). Two strands of either material are placed. A uterine packing forceps or other suitable long instrument is inserted into the superior most incision, into the peroneal sheath and advanced distally to exit the inferior incision. The tip of the forceps should be visible within the peroneal sheath distally (Figure 2, C and D). The tips of the forceps are spread with a thin instrument and the ends of one of the strands of umbilical tape or Fiberwire are placed in the jaws. The forceps are withdrawn from the superior incision along with the tips of the umbilical tape (Figure 2, E). The material is secured and then firmly pulled proximally, thereby splitting the peroneus longus into a posterior and anterior portion. The posterior limb of the tendon is transected in the proximal wound
FIGURE 1 Superior view of leg position for lateral ankle stabilization. The lateral border of the foot is essentially parallel to the floor. The proposed incisions have been delineated.
heel is held in maximal eversion and neutral ankle flexion by resting the medial surface of the foot on a bump. Substitution of the anterior talofibular ligament is facilitated by the remaining exposed portion of the peroneal tendon. The neck of the talus is exposed through a separate exposure and the natural insertion point of the ATF ligament is identified. A second channel for a second biotenodesis screw is created at that point with the same drill–guide wire technique (Figure 5, A). However the drill is not passed completely through the talus; rather, a 20-mm-deep channel is made. The foot is externally rotated and pushed posteriorly to minimize the distance between the anterior ridge of the fibula and the talar neck. The ligament is tensioned as well and secured with a second biotenodesis screw (Figure 5, B and C). Closure is performed in layers and the leg is placed in a short-leg splint or cast with the heel everted and the ankle at neutral. Postoperative Regimen
and then retracted from the distal wound with the second strand of suture material (Figure 2, F). Two converging 3.5-mm drill holes are made in the lateral aspect of the calcaneus in line with the natural course of the peroneus longus. The posterior-most hole should be just inferior to the calcaneal tubercle (Figure 3, A). A suture loop is then used to pass the free posterior limb of the peroneus longus from anterior to posterior through the osseous channel (Figure 3, A). A hemostat is used to create a corridor from the tip of the fibula to the drill hole, but must pass deep to the peroneal sheath (Figure 3, B). The anterior aspect of the fibula and lateral talofibular facet is exposed with a vertical incision centered over the lateral gutter. The channel for passage of the tendon-ligament graft is made in the distal fibula with a cannulated drill over a guide pin. Most commonly a 4.75-mm caliber biotenodesis screw is used. As such, a 5.5-mm drill is selected. The guide wire is placed at the tip of the fibula and directed toward the anterior ridge of the malleolus, corresponding to the point of attachment of the calcaneofibular ligament inferiorly and the anterior talofibular ligament superiorly (Figure 4, A). It is critical that the guide wire be centered within the cubic content of the lateral malleolus so as not to penetrate the fibular-talar facet (Figure 4, B). In addition, the instruments should be lavaged with saline to dissipate heat during the drilling process. A suture loop is then used to pass the peroneal tendon limb from the tip of the fibula to the anterior ridge of the fibula (Figure 4, C). Prior to passage, the peroneal tendon limb is passed deep to the peroneal tendon sheath to simulate the course of the calcaneofibular ligament. Once the tendon limb has been passed the heel is maximally everted and the tendon-ligament is tensioned. The tension from the calcaneus to the tip of the fibula is fixed with insertion of the biotendesis screw (Figure 4, D). For the duration of the procedure the
The patient is seen at the usual postoperative interval for suture removal and the extremity is placed in a short-leg cast with the heel fully everted and the ankle at neutral to protect the repaired ligaments. At 4 weeks postoperative, a neutral short-leg walking cast is applied. A removable cast boot is used at 6 weeks postoperative for an additional 2 weeks, followed by a physical therapy program comparable to any other lateral ankle stabilization protocol. Full sports activity is allowed at 12 weeks postoperatively. Discussion Ankle instability is a disabling condition that can be addressed by primary or secondary repair of the ATF and/or CFL ligaments. When reconstructing the lateral ankle ligaments, one must consider the goals of the procedure, restoring anatomic configuration, and encouraging a synergistic stabilization between the dynamic tendons and static ligaments. Studies comparing primary repair, anatomical tenodesis, and nonanatomical tenodesis have shown that an anatomical configuration provides a closer restoration of normal joint kinematics and pressures (9–13). The technique described herein has some distinct advantages compared with alternative ankle stabilization procedures. Most importantly it provides for reconstruction of both the calcaneofibular and anterior talofibular ligaments. Although good results have been reported for the Brostrom-type procedures in managing ankle instability, it is unclear whether the patients in these series had 2-ligament insufficiency (14–17). Moreover, there is a leap of faith to expect that plication of the residual ligament tissue adequately stabilizes the ankle. Furthermore, some patients may have insufficient integrity of the local tissue cuff, or
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FIGURE 2 (A) Intraoperative photograph showing the capture of the peroneus longus tendon in the proximal incision. The distal incision allows for longitudinal splitting of the peroneus longus tendon. (B) Close-up of tendon splitting. (C) Split peroneus longus tendon with 2 umbilical tapes looped around the posterior component of the divided tendon. The tips of the uterine packing forceps are visible within the sheath. (D) Wider view showing the placement of the forceps in preparation for tendon splitting. (E) Peroneus longus tendon has been split by retracting one of the umbilical tape loops proximally. The second loop is used distally for counter-traction. (F) Posterior limb has been transected in the proximal incision and withdrawn through the distal limb.
FIGURE 3 (A) Lateral view of the foot showing the 2 converging drill holes to create a bony tunnel in the lateral wall of the calcaneus. A suture loop is placed through the tunnel to pass the tendon from anterior to posterior through the tunnel. (B) Intraoperative photo showing development of channel for passage of the graft from the posterior calcaneal hole to the tip of the fibula. The corridor is created deep to the peroneal tendon complex, to replicate the course of the calcaneofibular ligament.
concomitant subtalar instability to preclude the use of ‘‘in situ’’ repairs (18). Anatomic repair of the insufficient ligaments is appealing because the insertion points of each ligament are restored. In turn, the normal kinematics of the affected joints, the ankle and subtalar, are maintained. This may be important, as the ankle and hindfoot complex is stressed through the entire range of motion during vigorous physical activity. Furthermore, the restoration of both of the affected ligaments in 702
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anatomic fashion eliminates the possibility of subtle or overt restriction of supinatory motion of the ankle that occurs in nonanatomic configurations (16). These changes include inhibition of hindfoot range of motion, loss of long-term stability, and medial degenerative changes (16). In effect, less satisfactory results are realized. The use of split peroneus longus (PL) tendon has been previously described for lateral ankle ligament reconstruction (19). The use of this structure is less biomechanically
FIGURE 4 (A) Insertion of the guide pin for creation of osseous channel in the distal fibula. The insertion point is the tip of the fibula to correspond to the anchor point of the calceaneofibular ligament. (B) Wider view showing the entrance and exit points of the guide wire. The wire exits the anterior ridge of the fibula to correspond to the attachment of the anterior talofibular ligament. (C) Suture loop placed from anterior to posterior through the osseous channel in the fibula. The loop passes deep to the peroneal tendons. In this case, the distal exposure was achieved through a single incision, as was done early in the development of the technique. (D) Intraoperative view showing the anchoring of the new calcaneofibular ligament to the distal fibula. Note that the heel is maximally everted by placing the medial aspect of the calcaneus, thereby elevating the extremity off of the operating table. The assistant applies traction to the tendon graft as the biotenodesis screw is inserted.
detrimental, as the PL tendon’s main function is to stabilize the first ray and the medial column, which may encourage hindfoot inversion (20). Therefore, the assumed loss of some power will reduce the supinatory thrust on the hindfoot complex and dampen the tendency for an inversion injury. Although there have been a number of methods proposed using the PB tendon, reduction of eversion strength has been demonstrated by almost 10% in the Evans and Chrisman-Snook procedures (1–4, 8). Although the PB can also be used in the technique herein, it makes little sense to potentially weaken an important everter and lateral stabilizing force of the lateral ankle and hindfoot. Furthermore, from a technical standpoint, the splitting of PB is often complicated by a shorter tendon and an enhanced muscle mass distally. Surgeons may find that the tendon length is insufficient for the obligate pathway of the reconstructed ligaments. The use of autologous tissue is also a distinct advantage for several reasons. First, allograft materials have a proclivity for soft tissue ‘‘creep’’ in that the new ligament will elongate with cyclical load. When autologous tissue is used, the propensity for soft tissue creep is determined by the prior load on the structure. As such, immediate harvest of autologous tissue strongly diminishes the potential to stretch out when placed in a new location under physiologic tension. Although soft tissue creep of an allograft can be mitigated
somewhat with pretensioning of the ligament, this takes additional time in the operating room and has not been shown conclusively to duplicate preharvest loads (21). Furthermore, the small but finite risk of disease transmission or increased risk of infection is eliminated. The capacity to harvest local autologous tissue is even more appealing because additional exposures at distant sites are avoided (22). Last, the use of allograft material adds to the overall cost of the operation. The use of interference screw technology allows the surgeon to modulate the tension of each ligament independently. This is advantageous because isometric tension of each ligament can be realized. It is important that ligaments are taut during the end of normal excursion of the respective joint it stabilizes. With this capability, the excursion can be tested intraoperatively and the ideal end point of calcaneal eversion can be fixed with placement of the first interference screw through the fibula. Anterior displacement of the talus occurs at the expense of rotation about an intact deltoid hinge and this can also be ‘‘dialed in’’ during the surgical procedure. One of the disadvantages of this stabilization procedure as well as all others is that the modulation of ligament tension cannot be quantitated. Yet a qualitative determinant of individual ligament tension is preferable to a global tightening of the entire soft tissue cuff on the lateral side of the ankle.
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FIGURE 5 (A) Intraoperative view of the anterior exposure. The lateral process of the talus is in full view and the guide pin for the biotenodesis screw is placed just anterior to correspond to the attachment of the anterior talofibular ligament. (B) The peroneus longus tendon graft is placed through the fibular tunnel and pulled anteriorly. Note the increased wrinkles in the skin resulting from external rotation and posterior displacement of the talus in the mortise. (C) Placement of the second biotenodesis screw over the guide pin. The final tension of the new anterior talofibular ligament is created just before seating of the biotenodesis screw with the talus in the external and posterior posture in the mortise.
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