Lateral Ankle Ligament Injuries in Athletes: Diagnosis and Treatment

Lateral Ankle Ligament Injuries in Athletes: Diagnosis and Treatment Adam T. Groth, MD, Gregory P. Guyton, MD, and Lew C. Schon, MD Nonsurgical management is preferred in most ankle sprains, even in the athletic population. However, patients presenting with chronic lateral ankle instability refractory to an appropriate bracing and rehabilitation program may benefit from lateral ligament reconstruction. Recognition and management of other associated injuries or conditions is critical to a successful outcome. We present 2 surgical techniques for reconstruction of the lateral ankle ligaments in athletes. The periosteal flap augmentation of the modified Broström reconstruction should be considered for primary cases. Patients who have failed prior surgical reconstruction or have a systemic condition resulting in generalized ligamentous laxity may require further surgical augmentation with an anatomical allograft ligament reconstruction technique. Oper Tech Sports Med 18:18-26 © 2010 Elsevier Inc. All rights reserved. KEYWORDS ankle, reconstruction, clinical, Broström, allograft

A

Diagnosis and Associated Injuries

Department of Orthopaedic Surgery, The Union Memorial Hospital, Baltimore, Maryland. Address reprint requests to Lew C. Schon, MD, Union Memorial Orthopaedics, The Johnston Professional Building, Suite 400, 3333 N Calvert Street, Baltimore, MD 21218. E-mail: [email protected]

History and physical examination remain the most accurate means of diagnosing lateral ankle instability. Patients complaining of chronic lateral ankle instability will usually give a history of a severe ankle inversion injury or multiple ankle sprains with a sense of giving way or frank instability. Isolated ankle instability will not usually cause pain. Therefore, other associated injuries must always be considered when pain between instability episodes is present in the intervals between sprains (Table 1). The physical examination of the unstable ankle is similar for other pathologic conditions of the lower extremity and should include inspection, palpation, range of motion testing, strength testing, gait evaluation, and specific testing for stability (Fig. 1). Mechanical instability implies that ankle laxity can be detected manually by the examiner. Functional instability means that a patient has a history of clinical instability episodes. A patient with mechanical instability may not have clinical symptoms because their peroneal tendons and neuromotor capabilities are able to provide the necessary supportive restraint. By contrast, pain resulting from other pathology around the foot and ankle can produce symptoms similar to functional instability in patients without mechanical laxity. One must maintain a high suspicion for other associated injuries when evaluating these patients, as this will effect treatment recommendations.

nkle sprains are the most common injuries in sports. Most are caused by an inversion force on the plantar flexed foot, resulting in injury to the lateral ankle ligament complex that consists of the anterior talofibular ligament (ATFL), the calcaneal-fibular ligament (CFL), and the posterior talofibular ligament. Symptomatic ankle instability may develop in as many as 20% of patients after a severe inversion ankle injury.1 Nonsurgical management is preferred in most ankle sprains, even in the athletic population. However, patients presenting with chronic lateral ankle instability refractory to an appropriate bracing and rehabilitation program may benefit from lateral ligament reconstruction. Recognition and management of other associated injuries or conditions is critical to a successful outcome. We present 2 surgical techniques for reconstruction of the lateral ankle ligaments in athletes. The periosteal flap augmentation of the modified Broström reconstruction should be considered for primary cases. Patients who have failed prior surgical reconstruction or have a systemic condition resulting in generalized ligamentous laxity may require further surgical augmentation with an anatomical allograft ligament reconstruction technique.

18

1060-1872/10/$-see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1053/j.otsm.2009.11.005

Lateral ankle ligament injuries in athletes Table 1 Associated Conditions With Lateral Ankle Ligament Injuries Bone Fracture (anterior process of calcaneus, lateral/posterior talar process, medial/lateral malleolus, base of 5th metatarsal) Subfibular ossicle Os trigonum Tibiotalar impingement Tarsal coalition Tumor Hindfoot varus alignment Cartilage Osteochondral lesion Nerve Tractional neuropraxia (superficial peroneal nerve, sural nerve) Tendon Peroneal tendonopathy Peroneal tendon tear Peroneal instability Painful os peroneum syndrome Peroneal weakness Soft tissue Sinus tarsi syndrome Anterolateral ankle soft tissue impingement Ligament Subtalar instability Syndesmosis injury Deltoid ligament instability Generalized ligamentous laxity

19 age, location, and size of the coalition will determine whether concomitant resection is indicated. Osteochondral lesions of the talus (OLT) are identified in 15%-25% of patients with chronic ankle laxity. These lesions will present with pain, swelling, and a sense of catching with active motion. A magnetic resonance image may be obtained if an OLT lesion is suspected. Ankle arthroscopy and appropriate management of the OLT lesion may then complement the lateral ligament reconstruction. Tractional nerve injury may also occur in severe ankle sprains and contribute to resultant weakness, paresthesias, pain, instability, and local tenderness or burning sensation.5,6 Surgical release and neurolysis may be beneficial in patients with significant neuralgia after an inversion ankle sprain.7 Peroneal tendon and retinacular pathology are the most common lesions associated with chronic ankle instability. This includes synovitis of the tendon sheath, longitudinal

Adapted with permission.2

In a review of 61 patients who underwent primary lateral ankle ligament reconstruction, DiGiovanni et al3 described 15 different associated injuries. None of these patients were found to have isolated lateral ligament injury. Strauss et al4 identified 6 associated extra-articular conditions in 115 (64%) of 180 ankles with chronic lateral instability. Secondary diagnoses to be considered may involve bone, cartilage, ligament, nerve, tendon, or other soft tissue lesions. Bony conditions include fractures (anterior process of the calcaneus, lateral or posterior talar process, medial or lateral malleolus, base of fifth metatarsal), subfibular ossicle, os trigonum, tibiotalar impingement, occult tumor, tarsal coalition, or hind foot varus alignment. Radiographs should be reviewed for all patients and correlated with point tenderness in a systematic examination of the entire foot and ankle. Depending upon the size and location of the fracture or osseous lesion, internal fixation or excision may be required. Foot shape and gait analysis are used to detect the presence of a cavovarus foot type or dynamic hind foot varus positioning. Hind foot varus may be addressed with a lateral closing wedge Dwyer calcaneal osteotomy in association with lateral ankle ligament reconstruction (Fig. 2). Tarsal coalitions are suspected with reduced subtalar motion and confirmed with radiographic studies, including computed tomography scans. Patient

Figure 1 Anterior drawer. (A) Allow the leg to hang freely with the foot plantar flexed to 25°. Stabilize the tibia with 1 hand and grasp the heel with the other. Pull the foot anteriorly while allowing it to rotate internally as it translates. Excessive anterior translation will be detected with an incompetent anterior talofibular ligament (ATFL). (B) A dimple or suction sign may be visible over the anterolateral corner of the joint.

20

A.T. Groth, G.P. Guyton, and L.C. Schon article focuses on the techniques of lateral ankle ligament reconstruction.

Surgical Procedures

Figure 2 Recognition of associated hind foot varus is critical to the success of lateral ankle ligament reconstruction.

tendon tears, and peroneal retinacular injury with resultant peroneal subluxation or dislocation.3 Peroneal tendon tears or retinacular pathology are suspected when direct f palpation or forced eversion against resistance causes tenderness along the peroneal tendons. Subluxation of the peroneal tendons is identified with resisted eversion stress testing. If present, operative exploration, debridement, and reconstruction are recommended. Peroneal muscle weakness (insufficiency) secondary to previous injury or neurologic deficit must also be considered, as it may result in inadequate ankle eversion to counteract inversion forces. Other soft-tissue lesions to consider include sinus tarsi syndrome, anterolateral ankle soft-tissue impingement, and ankle synovitis. Persistent sinus tarsi pain may ultimately be managed with subtalar arthroscopy.8 Hypertrophy of a portion of the anteroinferior tibiofibular ligament, also referred to as Bassett’s ligament, and accompanying synovitis may lead to impingement over the lateral corner of the talar dome and associated pain.9 Arthroscopic resection of Bassett’s ligament usually results in reliable pain relief without mechanical sequelae. Conditions with associated systemic ligamentous laxity must also be considered when evaluating these patients. The quality of the remaining tissues must be taken into account when planning a reconstruction, and these patients may require augmentation with allograft tissue. Generalized ligamentous laxity can be assessed using the Beighton score.10 This is measured by evaluating hyperextension of the knees, elbows, and small finger metacarpal phalangeal joints, as well as flexion of the thumbs to forearm testing and palms to floor hamstring stretch. Ligamentous pathology may further involve subtalar instability, syndesmotic injury, and medial (deltoid) instability. True subtalar instability is uncommon, but tears of the talocalcaneal interosseous ligament may cause pain and functional instability. Syndesmotic and deltoid tears are also severe injuries that may require further reconstruction. This

When planning lateral ankle ligament reconstruction, consideration must be given to maintaining proper ankle kinematics, particularly in the high demand athlete. A variety of techniques have evolved to include anatomical repair of the ligaments with and without augmentation, nonanatomical reconstruction using tenodesis, and anatomical reconstruction by tenodesis.11 The goal of anatomical reconstruction is direct repair of the lateral ligamentous complex with restoration of normal anatomy and kinematics, without restricting ankle or subtalar motion. A nonanatomical reconstruction does not rely on potentially attenuated and poor quality local tissues, but these tenodesis procedures have the disadvantage of altering normal ankle kinematics and restricting motion. Lateral ankle ligament reconstruction was first described by Broström in 1966. The initial Broström reconstruction was described as a midsubstance repair of the ATFL and has been shown to be an effective treatment for ankle sprains when disabling pain or instability persist.12-14 To further improve results with the Broström reconstruction, several adjunctive procedures have been described to supplement the anatomical repair. In 1980, Gould et al15 augmented the procedure by mobilizing and reattaching the lateral portion of the extensor retinaculum to the tip of the fibula. The Gould modification has been shown to be effective in an athletic population.15,16 Karlsson et al17 noted that the ATFL and CFL were usually elongated rather than disrupted and recommended shortening the ligaments and reattaching their anatomical origins.18-20 Several authors have also described the use of local periosteal flaps turned down from the fibula to augment direct repair.21-25 Periosteal autograft is a reliable substance to harvest, does not compromise other ligamentous or tendinous tissues, and does not carry the risks of allograft, xenograft, or synthetic materials.1,22 The biomechanical strength of a periosteal flap has been shown to be equivalent to that of the ATFL but less than peroneal tenodesis in a cadaver study.26 In 2 studies, a histologic examination of the flap after transfer showed remodeling of collagen fibers, with longitudinally aligned fibers in the direction of the ligaments.23,24 These data suggest that the use of a periosteal flap may be a good adjunct procedure when poor quality ligamentous tissue is found during a Broström repair or when additional repair strength is needed, with the possible limiting factor of the quality and dimensions of available periosteal tissue.1 Glas et al21 originally described a method of reconstructing the lateral ankle ligaments using a flap of periosteum taken off the fibula proximally and reflected distally. This technique split the flap and reinforced the ATFL and CFL repairs through separate mattress suture approximation. In another method, a local split periosteal flap is placed through drill holes, and bone plugs are used to secure the flap.24 These techniques do require more dis-

Lateral ankle ligament injuries in athletes section than the Broström procedures; however, a study of 90 patients still found more than 80% of the patients had good to excellent results.24 Okazaki et al23 reported on 13 patients with excellent results and mean American Orthopaedic Foot and Ankle Society foot score of 97.2 at 2 year follow-up using a similar periosteal flap technique to augment the ligamentous repair. We believe a periosteal flap can be used effectively in conjunction with a standard Broström reconstruction. This may be particularly advantageous as a primary procedure in the high-demand athlete. In our preferred technique, a rectangular pedicled periosteal flap is dissected and rotated over a Broström repair with Karlsson modification to reinforce the reconstruction. Indications for tendon graft augmentation of the lateral ligament reconstruction include a history of a failed Broström procedure, excessively attenuated soft tissues, or a genetic hypermobility disorder. Evans initially described a tenodesis of the peroneus brevis to the fibular periosteum. This procedure has been recently modified to divide the peroneus brevis, route a slip through a tunnel in the distal fibula, and suture it back to itself proximally. The Evans procedure effectively eliminates inversion instability but it does not prevent anterior translation of the talus on the tibia, and significantly limits subtalar motion. The Watson–Jones procedure provided a more anatomical reconstruction of the ATFL to gain control of the anterior translation. This was achieved by routing the peroneus brevis through a posterior-to-anterior tunnel in the fibula and then through a tunnel in the talar neck before suturing it back to itself at the fibular neck. This gave control of inversion stress and anterior translation, but still severely limited subtalar motion. The Chrisman–Snook procedure further modified the reconstruction by routing the anterior half of the peroneus brevis through a tunnel in the anterolateral neck of the talus, posteriorly through the fibula, and then inferiorly to the calcaneus. This was a better approximation of the ATFL and CFL but still limited subtalar motion. While no pure isometric reconstruction of the ATFL and CFL may be technically possible, investigation of anatomical tenodesis reconstructions have shown that these techniques may restore stability without sacrificing anatomy or kinematics.11 On the basis of their biomechanical studies, Colville et al devised an anatomically oriented lateral ligament reconstruction using a split peroneus brevis tendon graft routed through bone tunnels.27,28 In this technique the tendon is passed through a tunnel in the calcaneus and then through a posterior to anterior oblique tunnel in the fibula to reproduce the CFL. The tendon graft is then passed anteriorly through a bone tunnel in the anterior talar neck to reconstruct the ATFL. Mechanical stability and the maintenance of ankle kinematics and subtalar motion have been shown following this reconstruction.29,30 In our preferred technique for augmented anatomical lateral ligament reconstruction, we maintain the course of our graft and bone tunnels as described by Colville, but substitute a semitendinosis allograft for the peroneus brevis tendon.

21

Operative Technique—Periosteal Flap Augmentation of the Broström Lateral Ligament Reconstruction The Broström technique is done as previously described using the Karlsson modification to approximate the ATFL to the fibula.17 The procedure is performed with the patient supine. A bean bag or a bump placed under the hip is used to tilt the patient and facilitate exposure of the lateral ankle. Tourniquet use is optional. An approximately 5 cm curvilinear skin incision is made parallel to the posterior border of the distal fibula. It begins centered over the fibula at the level of the ankle joint, and extends to the dorsal aspect of the peroneal tendon sheath just distal to the tip of the fibula, curving into the sinus tarsi (Fig. 3A). If peroneal tendon pathology needs to be addressed, the incision is placed along the posterior border of the fibula and extended longitudinally. The subcutaneous tissues are initially dissected, and care must be taken to avoid the intermediate branch of the superficial peroneal nerve proximally (Fig. 4) and the sural nerve distally. The lesser saphenous vein may also cross the surgical field. Additionally, a prominent venous complex should be expected at the distal tip of the fibula. The extensor retinaculum is often torn or attenuated, but at times it may be identified and protected as a separate layer and can later be incorporated into the repair. Dissection is then carried down to the ankle joint capsule, and the regions of the fibular origin of the ATFL and CFL are identified. The ATFL originates 1 cm proximal to the distal tip of the fibula and inserts into the lateral talar neck just beyond the articular surface. This ligament is contiguous with the joint capsule as a discrete capsular thickening.31 The CFL originates adjacent to the ATFL on the fibula and travels obliquely to the calcaneus in a plantar and posterior direction. The CFL is extra-articular and is larger and stronger than the ATFL.31 The calcaneal insertion of the CFL runs

Figure 3 Incisions for lateral ankle ligament reconstruction. (A) modified Broström; (B) peroneal tendon exploration or anatomical allograft reconstruction; (C) Dwyer calcaneal osteomy.

22

Figure 4 The intermediate branch of the superficial peroneal nerve may approach the surgical field.

deep to the peroneal tendon sheath. The peroneal sheath is therefore routinely partially opened and the tendons are protected and retracted completely to allow visualization of the CFL. Proceeding proximal to distal, the ATFL and CFL are sharply released from their fibular origin leaving a 1-2 mm cuff of tissue that will be raised confluent with the fibular periosteal flap (Fig. 5). A bony avulsion from the tip of the fibula is sometimes encountered within the substance of the ligament. These ossicles may be a source of pain and should be excised carefully. If the ossicle is not identified properly, it may be mistaken for the tip of the distal fibula. This will lead to release of the lateral ligamentous complex too far distally from the true insertion on the distal fibula and may compromise the reconstruction. Once the ATFL and CFL have been divided the lateral ankle joint can be inspected (Fig. 5B). Loose bodies, anterior osteophytes, or lateral talar chondral lesions may be addressed at this time. Next, the periosteal flap is developed (Fig. 5C and D). Starting as distally as possible with the remnant cuff of ATFL insertion, a rectangular periosteal flap is sharply dissected from the anterior border of the fibula proceeding approximately 2 cm posteriorly and 4 cm proximally. The anterior aspect of the flap is released parallel to the anterior border of the fibula. At its most proximal extent, 4 cm from the distal tip of the fibula, a 2 cm perpendicular cut is made from anterior to posterior. Dissection is then continued to the lower 5-7 mm of the distal posterior fibula, paralleling the posterior border. The rectangular periosteal flap remains attached distally and posteriorly, but can be rotated anteriorly to overlap and augment the ATFL reconstruction. Once the periosteal flap has been created, the distal fibula is prepared. Using a small burr, chisel, or rongeur, a 4-mm trough is created along the anterior and inferior border of the distal fibula for reattachment of the ligaments at their origins. Using an 0.045-inch Kirschner wire, 3 drill holes are made in the lateral cortex of the distal fibula exiting through the trough (Fig. 5E). A 5-8 mm cortical bridge is preserved be-

A.T. Groth, G.P. Guyton, and L.C. Schon tween the holes. Two nonabsorbable sutures (Number 2-0 Ethibond) are passed through the bone tunnels to reapproximate the cut ends of the ATFL and CFL complex. The tissues are grasped with a Kessler type stitch, the suture limbs will share a common tunnel in the central hole. After the sutures have been passed, the heel is suspended by placing a stack of towels under the lower leg to prevent any anterior translation of the ankle, and the ankle is positioned in neutral dorsiflexion and slight eversion. The ligament is tensioned appropriately and the knots securely tied over the bony bridges from proximal to distal (Fig. 5F). The periosteal flap is then rotated over the ATFL repair so that it covers the entire ligament and is secured with an absorbable suture (Number 2-0 Vicryl) on a tapered needle. This may also serve to cover any exposed knots. The periosteal flap is layed flat and tensioned by first securing the superior corner near the level of the ankle joint (Fig. 5G). Gentle anterior drawer testing is performed to assess ankle stability. The ankle is then moved through a full range of plantarflexion and dorsiflexion to make certain that these motions have not been compromised by the repair. The wound is closed in layers and the skin approximated with an absorbable subcutaneous suture. The ankle is held in neutral dorsiflexion and slight eversion, and a posterior splint is applied. We prefer to institute an early weightbearing protocol with protected mobilization in a removable cast boot. Karlsson et al demonstrated that early mobilization allows for earlier return to sport and greater plantarflexion strength when compared with patients who have been immobilized.32,33 Safran et al reported that range of motion exercises can be performed in the sagittal plane to improve plantar- and dorsiflexion without undue stress to the ligaments after ankle sprain.34,35 These findings were further supported in a recent cadaveric model which showed that protected range of motion of the ankle after lateral ankle ligament reconstruction was not associated with elongation of the ATFL.36 Patients are transitioned to a removable cast boot 10-14 days following their reconstruction. At 2 weeks they are instructed on protected ankle range of motion with full active dorsiflexion, plantarflexion, and eversion, but avoiding inversion beyond neutral. They may begin gentle strengthening exercises, such as the stationary bike, and are also allowed to begin full weightbearing in a boot as tolerated, unless contraindicated by concomitant procedures. At 6 weeks the patient should be completely weightbearing and transition to an ankle stirrup orthosis or lace-up ankle brace for daytime use, but should continue to use the cast boot or a night splint when sleeping. Also, at 6 weeks, physical therapy is initiated with a supervised strengthening program. Once peroneal strength is normal, at 8-12 weeks, patients are allowed to return to progressive sport specific training and may advance from running, to figure-of-eights, to cutting activities. The patient may be released to full training and competition at 3-6 months depending upon their return of strength and specific demands.

Lateral ankle ligament injuries in athletes

Figure 5 Periosteal flap augmentation of the Broström lateral ligament reconstruction. (A) Release the ATFL and calcaneal-fibular ligament (CFL) origins from the distal fibula leaving a small cuff of tissue; (B) examine the lateral joint if indicated; (C) elevate the distal fibular periosteal flap, and (D) reflect posteriorly and distally; (E) after creating a trough in the distal fibula make 3 drill holes; (F) pass suture through drill holes and grasp the ATFL and CFL capsuloligamentous complex; (G) after securing the ligaments, overlay and secure the periosteal flap.

23

24

A.T. Groth, G.P. Guyton, and L.C. Schon

Figure 6 Anatomical lateral ligament reconstruction with semitendonosus allograft. (A) Divide the ATFL and CFL as previously described and expose the talar neck; (B) drill bone tunnels in the distal fibula and talar neck, then pass the all graft tendon through the distal fibula; (C) then route the tendon through the talar neck, and (D) return the free end through the same fibular tunnel; (E, F) secure the allograft with suture as it passes through the fibular tunnel; (G, H) and then tension and secure the remaining free ends at the insertion of the CFL.

Lateral ankle ligament injuries in athletes

Operative Technique—Anatomical Lateral Ligament Reconstruction with Semitendinosus Allograft A small bump is placed under the ipsilateral hip and the leg is suspended in a well leg holder. A noninvasive ankle distractor is applied. A diagnostic ankle arthroscopy is performed, and any intrarticular pathology is treated appropriately. After completion of the arthroscopy, the ankle distractor and well leg holder are removed. The ipsilateral hip bump remains in place and the lateral ankle is approached as described for the modified Broström technique above. If a lateral closing wedge Dwyer calcaneal osteotomy is indicated to correct a varus hind foot deformity, a separate 4 cm oblique incision is made over the lateral aspect of the calcaneus, posterior to the sural nerve (Fig. 3C). Attempts to perform a calcaneal osteotomy and ligament reconstruction through the same incision often result in sural nerve injury and should be avoided. An approximately 7-cm incision is then made over the distal fibula curving into the sinus tarsi (Fig. 3B). The sural nerve is protected and the peroneal tendons are identified and mobilized anteriorly. The calcaneal insertion of the CFL is then accessed and roughened down to periosteam with a rongeur in anticipation of later insertion of the graft. Next the origins of the ATFL and CFL are elevated off the anterior and distal margins of the fibula with a small sleeve of soft tissue and periosteum, the peroneal tendons are protected and explored if indicated. The talar neck-body junction is then exposed (Fig. 6A). The extensor retinaculum and ankle joint capsule may need to be carefully divided with a small T-cut to allow adequate visualization. Convergent bone tunnels are then made in the talus and distal fibula and widened with a 4 mm burr. The talar tunnels are aligned in a vertical fashion with a 1-cm cortical bridge along the insertion of the ATFL, which has been elevated at the neck-body junction. Corresponding convergent tunnels are then made within the fibula at the origin of the ATFL on the anterior border 1 cm proximal to the tip, and inferiorly at the origin of the CFL. The fibular tunnel must be widened to a greater degree to accommodate 2 passes of the allograft tendon. A semitendinosus allograft trimmed to 5-6 mm in diameter and measuring at least 10 cm in length is preferred. The ends of the tendon are whipstitched and routed through the bony tunnels to recreate the anatomical course of the ATFL and CFL. The first pass of the allograft begins through the fibular tunnel from distal to proximal (Fig. 6B). The leading end is then brought from distal (plantar) to proximal (dorsal) through the talar tunnel, and passed through the fibula a second time from proximal to distal (Fig. 6C and D). Both ends of the allograft are then passed under the peroneal tendons to the insertion of the CFL, which had been prepared earlier. The leg is placed on a bump, and the heel is suspended to avoid anterior translation. An assistant maintains the ankle in neutral dorsiflexion and slight eversion. The graft is then

25 tensioned and secured in 2 steps. First, two 0.062-inch Kirschner wire drill holes are made from the lateral fibular surface into the proximal fibular tunnel (Fig. 6D). Tension is applied to the allograft, and a nonabsorbable suture (Number 1 Silky Polydek) is passed through the drill holes and the allograft as it courses into the tunnel, to secure the ATFL portion of the reconstruction (Fig. 6E). Next the CFL limb of the reconstruction is fastened. Care must be taken to protect the peroneal tendons and sural nerve. The position of the ankle is maintained while the tail limbs of the tendon are tensioned, and the allograft is secured at the CFL insertion site with a small soft tissue staple or interference screw (Fig. 6G and H). The capsuloligamentous sleeve of native ATFL and CFL is then reattached to the distal fibula either through drill holes, as described in the previous technique, or figure-of-8 stitches with an absorbable suture (Number 0 Vicryl). The wound is closed in layers and a splint is applied. The rehabilitation program follows a similar but delayed course as that previously described. The patient will remain non-weight-bearing and immobilized in a removable boot brace for a full 4 weeks before initiating therapy.

References 1. Colville MR: Surgical treatment of the unstable ankle. J Am Acad Orthop Surg 6:368-377, 1998 2. Berlet GC, Anderson RB, Davis WH: Chronic lateral ankle instabiliaty. Foot Ankle Clin 4:713-728, 1999 3. Digiovanni BF, Fraga CJ, Cohen BE, et al: Associated injuries found in chronic lateral ankle instability. Foot Ankle Int 21:809-815, 2000 4. Strauss JE, Forsberg JA, Lippert FG III: Chronic lateral ankle instability and associated conditions: A rationale for treatment. Foot Ankle Int 28:1041-1044, 2007 5. Nitz AJ, Dobner JJ, Kersey D: Nerve injury and grades II and III ankle sprains. Am J Sports Med 13:177-182, 1985 6. O’Neill PJ, Parks BG, Walsh R, et al: Excursion and strain of the superficial peroneal nerve during inversion ankle sprain. J Bone Joint Surg Am 89:979-986, 2007 7. Johnston EC, Howell SJ: Tension neuropathy of the superficial peroneal nerve: Associated conditions and results of release. Foot Ankle Int 20:576-582, 1999 8. Frey C, Feder KS, DiGiovanni C: Arthroscopic evaluation of the subtalar joint: Does sinus tarsi syndrome exist? Foot Ankle Int 20:185-191, 1999 9. Bassett FH III, Gates HS III, Billys JB, et al: Talar impingement by the anteroinferior tibiofibular ligament. A cause of chronic pain in the ankle after inversion sprain. J Bone Joint Surg Am 72:55-59, 1990 10. Beighton PH, Horan FT: Dominant inheritance in familial generalised articular hypermobility. J Bone Joint Surg Br 52:145-147, 1970 11. DiGiovanni CW, Brodsky A: Current concepts: Lateral ankle instability. Foot Ankle Int 27:854-866, 2006 12. Bell SJ, Mologne TS, Sitler DF, et al: Twenty-six-year results after Broström procedure for chronic lateral ankle instability. Am J Sports Med 34:975-978, 2006 13. Broström L: Sprained ankles. VI. Surgical treatment of chronic ligament ruptures. Acta Chir Scand 132:551-565, 1966 14. Javors JR, Violet JT: Correction of chronic lateral ligament instability of the ankle by use of the Broström procedure. A report of 15 cases. Clin Orthop Relat Res 198:201-207, 1985 15. Gould N, Seligson D, Gassman J: Early and later repair of lateral ligament of the ankle. Foot Ankle 1:84-89, 1980 16. Hamilton WG, Thompson FM, Snow SW: The modified Broström procedure for lateral ankle instability. Foot Ankle 14:1-7, 1993; erratum 180

26 17. Karlsson J, Bergsten T, Lansinger O, et al: Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg Am 70:581-588, 1988 18. Karlsson J, Bergsten T, Lansinger O, et al: Surgical treatment of chronic lateral instability of the ankle joint. A new procedure. Am J Sports Med 17:268-273, 1989 19. Karlsson J, Eriksson BI, Bergsten T, et al: Comparison of two anatomic reconstructions for chronic lateral instability of the ankle joint. Am J Sports Med 25:48-53, 1997 20. Krips R, Van Dijk CN, Halasi PT, et al: 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 21. Glas E, Paar O, Smasal V, et al: Periosteal flap reconstruction of the external ankle ligaments. Results of a follow-up study. Unfallchirurg 88:219-222, 1985 22. Kirk KL, Schon LC: Technique tip: Periosteal flap augmentation of the Broström lateral ankle reconstruction. Foot Ankle Int 29:254-255, 2008 23. Okazaki K, Miyagi S, Tokunaga J: Anatomic reconstruction of the lateral ligament of the ankle using a periosteal flap from the fibula. Tech Foot Ankle Surg 4:98-103, 2005 24. Rudert M, Wulker N, Wirth CJ: Reconstruction of the lateral ligaments of the ankle using a regional periosteal flap. J Bone Joint Surg Br 79: 446-451, 1997 25. Sjolin SU, Dons-Jensen H, Simonsen O: Reinforced anatomical reconstruction of the anterior talofibular ligament in chronic anterolateral instability using a periosteal flap. Foot Ankle 12:15-18, 1991 26. Bohnsack M, Surie B, Kirsch IL, et al: Biomechanical properties of commonly used autogenous transplants in the surgical treatment of chronic lateral ankle instability. Foot Ankle Int 23:661-664, 2002

A.T. Groth, G.P. Guyton, and L.C. Schon 27. Colville MR, Grondel RJ: Anatomic reconstruction of the lateral ankle ligaments using a split peroneus brevis tendon graft. Am J Sports Med 23:210-213, 1995 28. Colville MR, Marder RA, Zarins B: Reconstruction of the lateral ankle ligaments. A biomechanical analysis. Am J Sports Med 20:594-600, 1992 29. Bahr R, Pena F, Shine J, et al: Biomechanics of ankle ligament reconstruction. An in vitro comparison of the Broström repair, Watson–Jones reconstruction, and a new anatomic reconstruction technique. Am J Sports Med 25:424-432, 1997 30. Schmidt R, Cordier E, Bertsch C, et al: Reconstruction of the lateral ligaments: Do the anatomical procedures restore physiologic ankle kinematics? Foot Ankle Int 25:31-36, 2004 31. Burks RT, Morgan J: Anatomy of the lateral ankle ligaments. Am J Sports Med 22:72-77, 1994 32. Karlsson J, Lundin O, Lind K, et al: Early mobilization versus immobilization after ankle ligament stabilization. Scand J Med Sci Sports 9:299-303, 1999 33. Karlsson J, Rudholm O, Bergsten T, et al: Early range of motion training after ligament reconstruction of the ankle joint. Knee Surg Sports Traumatol Arthrosc 3:173-177, 1995 34. Safran MR, Benedetti RS, Bartolozzi AR III, et al: Lateral ankle sprains: A comprehensive review. Part 1: Etiology, pathoanatomy, histopathogenesis, and diagnosis. Med Sci Sports Exerc 31:S429-S437, 1999 35. Safran MR, Zachazewski JE, Benedetti RS, et al: Lateral ankle sprains: A comprehensive review. Part 2: Treatment and rehabilitation with an emphasis on the athlete. Med Sci Sports Exerc 31:S438-S447, 1999 36. Kirk KL, Campbell JT, Guyton GP, et al: ATFL elongation after Broström procedure: A biomechanical investigation. Foot Ankle Int 29:1126-1130, 2008