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Lateral ligament reconstruction of the ankle: comparative study of peroneus brevis tenodesis versus periosteal ligamentoplasty
Foot and Ankle Surgery 1998
4:71-76
Lateral ligament reconstruction of the ankle: comparative study of peroneus brevis tenodesis versus periosteal ligamentoplasty C. MABIT, J.M. C H A U D R U C , F. F I O R E N Z A , H. H U C A N D C. P E C O U T Department of Orthopaedic Surgery, Dupuytren's Hospital, University of Limoges, France
Summary Lateral chronic instability of the ankle represents 10-30% of ankle sprain sequelae. This study compares the results of two procedures: peroneus brevis tenodesis (PBT) and periosteal flap graft (PFG). The two series were composed by: 24 PBT, 22 PFG; all patients practised sports and 59% were competitors. The mean follow-up is 5.5 years for the PBT and 3 years for the PFG. The results were evaluated both clinically (according the functional rating scale of Good-Jones-Livingstone) and radiologically with pre- and postoperative stress tests (talar tilt, anterior drawer test). Sports resumption evaluation was also recorded. These results show better functional outcome for the periosteal procedure (91% success rate) compared to the peroneus brevis procedure (54% success rate). Functional results were statistically correlated (Fischer's test) with stability improvement evaluated on radiological stress test. Clinical outcome discrepancies may be explained by a biomechanical perspective: anatomical reconstructive procedure of the anterior talofibular ligament is a better technique to preserve the talar joint adaptative function.
Keywords: ankle instability; ankle lateral ligament reconstruction; periosteal ligamentoplasty; peroneus brevis tenodesis
Introduction Lateral ankle sprain is a common injury. It has been estimated that there is about one inversion injury of the ankle per 10 000 persons per day [1]. Ankle sprains account for 25-50% of injuries in sports and athletics [2--4]. Chronic lateral ankle instability represents 10-30% [5-7] of ankle sprain sequellae which can
Correspondence: Professor C. Mabit, Service d'Orthop6die Traumatologie, Centre Hospitalier Universitaire Dupuytren, 2, Av. Martin Luther King, 87042Limoges,France.
© 1998 BlackwellScienceLtd
severely impair sports performance. This type of instability implies lesions of the fibular lateral ligament complex and specifically the anterior talofibular ligament which acts as the primary restraint for the ankle at all angles of flexion [8, 9]. Mechanical and functional instability may be parallel phenomena but they are not strictly correlated [6, 10]. More than 50 reconstructive procedures for ankle ligamentoplasty have been described using: direct suture or reinsertion of torn ligaments; capsular shift [11-14]; ligamentoplasties with the peroneus brevis tendon [3, 15-18]; the inferior retinaculum extensor 71
C. MABIT ET AL.
72
20 151
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10
:':':[:.
5
L-St>L! ,?p-
:[:-5
Recreational Soccer
Tennis
Jude
Basket
Athletics Gymnastics
Sport
Figure 1 Sporting activities.
2
'
1
Figure 2 Peroneus brevis ligamentoplasty (Castaing procedure). The peroneus brevis tendon is passed through the transmalleolar antero-posterior tunnel and sutured to itself. (1) Inferiorextensor retinaculum. (2) Peroneus brevis. (3) Peroneus longus. (4) Transmalleolartunnel.
[19]; the plantaris tendon [5, 20]; the Achille's tendon [21], or the peroneus tertius [22]. The aim of this retrospective study is to compare two procedures: (1) a tenodesis with the peroneus brevis tendon (PBT) as described by Castaing [15, 23]; (2) an anatomical reconstruction of the anterior talofibular ligament with a periosteal flap graft (PFG) [24] which has recently gained popularity [25-29]. Materials
and methods
Patients This retrospective study includes 46 patients who underwent lateral ligamentous reconstructive procedures of the ankle. Twenty-four consecutive patients (15 men and nine women) aged 15-44 years (mean 27), were treated
with PBT. The mean delay between the initial episode of ankle sprain and the operation was 4 years (range, 3 months-15 years). Thirteen patients practised competition sports and 11 recreational sports. Twenty-two consecutive patients (13 men and nine women) aged 14-41 years (mean 21), were treated with PFG. The mean delay between the initial injury and the operation was 6 years (range, 2 months-17 years). Fourteen patients practised competition sports and eight recreational sports. The majority of the patients recalled several ankle sprains (a mean of 3) leading to chronic instability and functional impairment in athletic activities a n d / o r social life. Soccer was the most frequently concerned sport (Figure 1). There was no difference in the treatment of the initial accident between the two groups: for the majority of cases, initial treatment included plaster cast (with a mean duration of immobilization of 3 weeks) followed by a rehabilitation programme. However, a remarkable number of ankle sprains remained medically untreated (19/46).
Surgical protocols Peroneus
brevis
tendon.
A conventional lateral approach is used: the peroneus brevis is released and severed in its proximal part so as to free the distal 15cm of the tendon (the muscular part is sutured to the peroneus longus). Then a tunnel is drilled perpendicularly in the distal part of the lateral malleolus. The tendon is passed from back to front in this tunnel and sutured to itself with the foot in neutral position. The sutures are progressively tightened so as to obtain an optimal tension of the graft (Figure 2).
Periosteal flap graft. The procedure is performed through a lateral approach with a more proximal extension. Care should be taken with the superficial fibular nerve. The lateral malleolus and the neck of the talus are then exposed. The fibular periosteum is dissected with a rasp to at least l c m width and 12cm length, then a tunnel is vertically drilled through the talar neck. The graft is secured by a suture at its distal insertion to the periosteum of the anterior border of the lateral malleolus. The graft is then © 1998 BlackwellScience Ltd,Footand Ankle Surgery,4, 71-76
LATERAL LIGAMENT
RECONSTRUCTION
OF THE ANKLE
73
Table 2
Functional results
3
1
PBT group~
PFG groupJ-
7 6 8 3
10 10 0 2§
Grade 1 Grade 2 Grade 3 Grade 4
Mean follow-up: 5.5 years. ~-Mean follow-up: 3 years. § One failure after a secondary traumatic rupture in a soccer player who had fully resumed sports. Figure 3
Periosteal ligamentoplasty (Roy-Camille-Saillant procedure). The periosteal flap is individualized; its distal malleolar insertion is preserved. The graft is then passed through the transosseous tunnel drilled in the talar neck and sutured to itself. The anterior talofibular ligament is restored in an anatomical position. (1) Inferior extensor retinaculum. (2) Periosteal flap graft. (3) Transosseus tunnel drilled in talar neck. Table 1
Good-Jones-Livingstone Grading System of lateral ligament instability Grade
Description
Full activity, including strenuous sports. No pain, swelling or giving way. Occasional aching, only after strenuous exercise. No giving way or feeling of apprehension. No giving way but some remaining apprehension, especially on rough ground. Recurrent instability and giving way in normal activities, with episodes of pain and swelling.
p a s s e d t h r o u g h the talar tunnel and s u t u r e d to itself w i t h the foot in neutral position (Figure 3). For b o t h procedures, p o s t o p e r a t i v e i m m o b i l i z a t i o n is achieved t h r o u g h a leg brace for 5 weeks; w e i g h t bearing on crutches is authorized for at least 3 weeks. Then a rehabilitation p r o g r a m m e is initiated w h i c h incorporates not only the usual elements of physical therapy, such as strength a n d flexibility, b u t also activities to enhance p r o p r i o c e p t i o n a n d n e u r o m u s c u l a r control.
Methods
Results h a v e b e e n e v a l u a t e d b o t h clinically a n d radiographically. In order to standardize the results for c o m p a r a t i v e studies, the functional g r a d i n g s y s t e m established by G o o d et al. [30] (Table 1) a n d p r e v i o u s l y u s e d b y Sefton et al. [31] has b e e n used. © 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 71-76
Stiffness w a s also recorded: an i m p a i r m e n t of 10 ° or m o r e in the r a n g e of m o t i o n (ROM) w a s considered to be significant. R e s u m p t i o n of sport w a s also evaluated b y the n u m b e r of patients returning to a competitive level of practice. Comparative and postoperative radiologicat findings w e r e b a s e d on s t a n d a r d or intensified i m a g e s and stress r a d i o g r a p h s (talar tilt a n d anterior d r a w e r tests) w e r e p e r f o r m e d manually. Statistical correlation of functional and r a d i o g r a p h i c results w a s carried out b y the Fischer test.
Results
Follow-up r a n g e d f r o m 1 to 15 years with a m e a n of 5.5 years for PBT, a n d f r o m 1 to 4 years w i t h a m e a n of 3 years for PFG.
Clinical results
The overall results in the PBT g r o u p w e r e excellent in seven ankles (grade 1), g o o d in six (grade 2), fair in eight (grade 3) a n d p o o r in three (grade 4). In the PFG group, the result ratings w e r e excellent in 10 ankles, g o o d in 10 a n d p o o r in t w o (Table 2). Seventeen patients w h o u n d e r w e n t PBT s h o w e d significant (_> 10 °) loss in R O M as c o m p a r e d to only two patients treated b y PFG. H o w e v e r , in this series ROM is not statistically correlated w i t h clinical results. Sports r e s u m p t i o n evaluation s h o w e d that 45.5% of the patients w h o u n d e r w e n t PFG r e s u m e d their
74
C. M A B I T E T A L .
t-
r-
'~ n
3 "
J3-
Same level
Inferior level
II
Stop personal reasons
Same level
Stop ankle disability
Resumption of sport Figure 4
Functional results of periosteal flap graft. I , competitive sport; D, recreational sport.
Inferior level
Stop personal reasons
Stop ankle disability
Resumption of sport Figure 5
Functional results of peroneus brevis tenodesis. II, competitive sport; El, recreational sport. Table 3
s p o r t i n g activities at the s a m e level (Figure 4) while o n l y 29% of the patients w h o h a d PBT w e r e able to r e s u m e their activities (Figure 5). Two patients (9%) f r o m the PFG g r o u p c o u l d n o t r e s u m e sports d u e to persistant ankle p a i n or instability versus 11 patients (45.8%) in the PBT g r o u p . The PBT series results w e r e c o m p l i c a t e d b y three r u p t u r e s of the transplant, f o u r cases of severe loss of articular mobility, t w o n e u r o m a of the sural n e r v e a n d one a l g o d y s t r o p h i c s y n d r o m e . The PFG series results w e r e c o m p l i c a t e d b y t w o r u p t u r e s of the transplant. In the first case of failure, the periosteal graft w a s said to be ' w e a k ' o n the surgical report; the s e c o n d one w a s a s e c o n d a r y t r a u m a t i c r u p t u r e in a soccer p l a y e r w h o h a d fully r e s u m e d sports.
Radiological results
L o n g - t e r m stress r a d i o g r a p h s s h o w e d better results for the PFG l i g a m e n t o p l a s t y series w i t h n o case of
Radiological results (laximetry) Laximetry
Talar tilt <5° 5°-10 ° 10°-15° >15° Not done Anterior drawer test <8mm 8-15mm >15mm Not done
PBT group
PFG group
Preop
Postop
Preop
Postop
0 6 12 6 0
12 7 4 1 0
0 6 13 3 0
17 3 0 0 2
0 13 6 5
9 12 3 0
0 13 4 5
20 0 0 2
increased talar tilt (>10 °) or increased anterior d r a w e r test ( > 8 m m ) versus five patients (21%) a n d 15 p a t i e n t s (62.5%) in the PBT series, respectively. A g o o d functional result is statistically correlated (Fischer's test), w i t h a talar tilt <5 ° (P<0.01) a n d an anterior d r a w e r test < 8 m m (P<0.02) (Table 3). © 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 71-76
LATERAL LIGAMENT
O n e case w i t h osteoarthritic c h a n g e w a s r e p o r t e d in the PBT g r o u p .
Discussion T h e m o s t w i d e l y p e r f o r m e d p r o c e d u r e s in the past have been non-anatomic reconstructions with tenodesis u s i n g the p e r o n e u s brevis [16-18, 32-35]. M a n y studies h a v e s h o w n g o o d s h o r t - t e r m results, b u t the l o n g - t e r m results h a v e d e t e r i o r a t e d w i t h time, especially in y o u n g athletes. A n a t o m i c a l reconstructions, w i t h or w i t h o u t augmentation, have been chosen by many authors d u r i n g recent y e a r s b e c a u s e of the b i o m e c h a n i c a l a n d clinical d r a w b a c k s w i t h n o n - a n a t o m i c t e c h n i q u e s [2, 28, 36-39]. I n the p r e s e n t study, the overall o u t c o m e of the c o m p a r i s o n b e t w e e n the t w o p r o c e d u r e s t e n d s to f a v o u r PFG. As stated b y several a u t h o r s [8, 23, 39], better f u n c t i o n a l results are correlated w i t h a n a t o m ical r e c o n s t r u c t i v e p r o c e d u r e s . The R O M w a s m o r e o f t e n felt to be d i s t u r b e d after p e r o n e a l tenodesis. These o b s e r v a t i o n s are c o n f i r m e d b y f o r m e r l y p u b l i s h e d d a t a [40-43]. Visser et aI. [44] h a v e r e p o r t e d t h a t limitation of the R O M after tenodesis w a s n o t infrequent. B r u n n e r a n d G a e c h t e r [45], R o y Camille et al. [27], Visser et al. [44], D r a e n e r t a n d M(iller [46] a n d K a r l s s o n et al. [47] stress that a n a t o m i c a l l y accurate t e c h n i q u e s of l i g a m e n t o u s r e c o n s t r u c t i o n are m o r e closely linked w i t h p r e s e r v e d R O M a n d g o o d stability of the ankle joint. Biomechanically, these t w o t y p e s of r e c o n s t r u c t i o n are v e r y different. PBT uses graft material ( p e r o n e u s brevis t e n d o n ) s e c u r e d in a n o n - a n a t o m i c a l position, t h e r e b y e r a d i c a t i n g a n active stabilizer of the ankle a n d l o c k i n g the sub-talar joint. PFG is an a n a t o m i c a l r e c o n s t r u c t i o n w h i c h p r e s e r v e s the lateral active stabilizers of the ankle. The success of this t y p e of r e c o n s t r u c t i o n relies o n the quality of the periosteal graft, w h i c h varies a c c o r d i n g to age, sex a n d m o r p h o t y p e [26]. O n the basis of an isometric p o s i t i o n i n g of ligaments insertion, as u s u a l l y a c c e p t e d in k n e e surgery, w e h a v e b e g u n a p r e l i m i n a r y stt~dy e v a l u a t i n g a n original graft p r o c e d u r e u s i n g the p e r o n e u s tertius t e n d o n . Initial result s h o w e q u i v a l e n t a n a t o m i c a l a n d b i o m e c h a n i c a l a d v a n t a g e s b u t require f u r t h e r clinical e v a l u a t i o n [22]. © 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 71-76
RECONSTRUCTION
OF THE ANKLE
75
Conclusion O n the basis of these results, a n a t o m i c a l reconstruction can be r e c o m m e n d e d : it is e a s y to p e r f o r m , has a l o w rate of c o m p l i c a t i o n a n d gives satisfactory m e c h a n i c a l stability. I n o u r series, PFG has p r o d u c e d a 91% success rate o v e r a 3 y e a r s follow-up, a n d PBT has a 54% success rate. In y o u n g athletes, better functional results c a n be e x p e c t e d w i t h a n a t o m i c a l r e c o n s t r u c t i o n at follow-up.
References 1 Brooks SC, Potter BT, Rainey JB. Treatment for partial tears of the lateral ligament of the ankle: a prospective trial. Br Med J 1981; 282: 606-607. 2 Balduini F, Vergso JJ, Torg JS, Torg E. Management and rehabilitation of ligamentous injuries to the ankle. Sports Med 1987; 4: 364-380. 3 Garrick JG. The frequency of injury, mechanism of injury and epidemiology of ankle sprains. Am J Sports Med 1977;5: 241-242. 4 Mack RP. Ankle injuries in athletes. Clin Sports Med 1982; 1: 71-84. 5 Anderson ME. Reconstruction of the lateral ligaments of the ankle using the plantaris tendon. J Bone Joint Surg 1985; 67A: 930-934. 6 Freeman M, Dean M, Hanham I. The etiology and prevention of functional instability of the foot. ] Bone Joint Surg 1965; 47B: 678-685. 7 Peters JW, Trevino SG, Renstrom P. Chronic lateral ankle instability. Foot Ankle 1991; 12: 182-191. 8 Burks RT, Morgan J. Anatomy of the Idteral ankle ligaments. Am J Sports Med 1994; 22: 72-77. 9 Johnson E, Marklof KL. The contribution of the anterior talofibular ligament to ankle laxity. J Bone Joint Surg 1983; 65A: 81-88. 10 Tropp H. Functional instability of the ankle joint. Medical Dissertation. LinkOping University, 1985. 11 Blancher A. La r6fection capsuloqigamentaire dans les instabilit6s chroniques de la tibio-tarsienne. Rev Chir Orthop 1975; 61 (Suppl 2): 175-176. 12 Christet P, Witwoet J, Jaulin P. Traitement chirurgical des instabilit6s tibio-tarsiennes chroniques chez le sportif par retention transosseuse du plan capsulo-ligamentaire externe: propos de 28 cas. J Traumatol Sport 1988; 5: 177-184. 13 Duquennoy A, Fontaine C, Martinot JC et aL Instabilit6 chronique de l'articulation tibio-tarsienne remise en tension ligamentaire externe: apropos de 58 cas revus. Rev Chit Orthop 1989; 75: 387-393. 14 Gould N. Repair of lateral ligament of the ankle. Foot Ankle 1987; 2: 55-58. 15 Castaing J, Le Chevalier PL, Meunier M. Entorse ~ r6p6tition ou subluxation r6cidivante de la tibio-tarsienne: une technique simple de ligamentoplastie externe. Rev Chir Orthop 1961; 47: 598-608. 16 Christman OD, Snook GA. Reconstruction of lateral ligaments 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 1969; 51A: 904-912.
76
C. MABIT
ET AL.
17 Evans DL. Recurrent instability of the ankle: a method of surgical treatment. J R Soc Med 1953; 46: 343-344. 18 Watson-Jones R. Fractures and Joint Injury, Vol. 2, 4th edn. Baltimore: Williams & Wilkins, 1955. 19 Segal P, Dehoux E, Deprey F et al. Le traitement chirurgical des laxit6s externes chroniques de la cheville par ligamentoplastie au frondiforme. J Traumatol Sport 1991; 8: 24-27. 20 Weber BG, Hupfauer W. Zur Behandlung der frischen fibularen Bandruptur und der chronischen fibularen Bandinsuffizienz. Archiv Orthop Unfallchir 1969; 65: 215. 21 Solheim L, Denstad T. Chronic lateral instability of the ankle: a method of reconstruction using the Achilles tendon. Acta Orthop'Sca~d 1980; 51: 193-196. 22 Mabit C, Pecout C, Arnaud JP. La ligamentoplastie au troisi6me fibulaire (p6roneus tertius) dans les laxit6s lat6rales de la cheville: tect~ique chirurgicale. Rev Chir Orthop 1996; 82: 70-75. 23 Castaing J, Falaise B, Burdin P. Ligamentoplastie au court p6ronier lat6ral dans le traitement des instabilit6s chroniques de la cheville: r6vision a long terme. Rev Chir Orthop 1984; 70: 653-656. 24 Katzenstein M. Die plastische Bildung von Gelenkbandern. Med Klin 1924; 19: 1392-1395. 25 Kuner EH. Der gestielte Periostztigel als M6glichkeit des Augenbandersatzes. Hefte Unfallheilk 1978; 133: 191-193. 26 Mabit C, Setton D, Charissoux JL et al. La ligamentoplastie au p6rioste dans les instabilit6s chroniques de la cheville chez le sportif. J Traumatol Sport 1993; 10: 102-105. 27 Roy-Camille R, Saillant G, Gagna G, Benazet JP, Feray C. Les laxit6s externes chroniques de la cheville: cure chirurgicale par une ligamentoplastie au p6rioste. Rev Chir Orthop 1986; 72: 121-126. 28 Sjolin SU, Dons-Jensen H, Simonsen O. Reinforced anatomical reconstruction of the anterior talo-fibular ligament in chronic anterolateral instability using a periosteal flap. Foot Ankle 1991; 12: 15-18. 29 Wirth CJ. Die modifizierte Periostlappenplastik nach Kuner bei chronischer Instabilitat des fibularen Kapsel-Band-Apparates. Operat Orthop Traumatol 1991; 3: 196-202. 30 Good CJ, Jones MA, Livingstone BN. Reconstruction of the lateral ligament of the ankle injury. 1975; 7: 63-65.
31 Sefton GK, George J, Fitton JM, McCullen H. Reconstruction of the anterior talofibular ligament for the treatment of the instable ankle. J Bone Joint Surg 1979; 61B: 352-354. 32 Barbari SG, Brevig K, Egge T. Reconstruction of the lateral ligamentous structures of the ankle with a modified Watson-Jones procedure. Foot Ankle 1987; 6: 362-368. 33 Elmslie RC. Recurrent subluxation of the ankle joint. Ann Surg 1934; 100: 364-367. 34 Lee HG. Surgical repair in recurrent dislocation of the ankle joint. J Bone Joint Surg 1957; 39A: 828-834. 35 Liu SH, Baker CL. Comparison of lateral ankle ligamentous reconstruction procedures. Am J Sports Med 1994; 22: 313-317. 36 Gould N. Early and late repair of lateral ligament of the ankle. Foot Ankle 1980; 1: 84-89. 37 Hamilton WG, Thompson FM, Snow SW. The modified Brostr6m procedure for lateral ankle instability. Foot Ankle 1993; 14: 1-7. 38 Karlsson J, Bergsten T, Lansinger O et aL Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg 1988; 70A: 581-588. 39 LOfvenberg R, Karrholm J, Ahlgren O. Ligament reconstruction for ankle instability: a 5-year prospective RSA follow-up of 30 cases. Acta Orthop Scand 1994; 65: 401-407. 40 Vainiopaa S, Kirves P, Laike E. Lateral instability of the ankle and results when treated by the Evans procedure. Am J Sports Med 1980; 8: 437-439. 41 Brostrom L. Sprained ankles. VI: Surgical treatment of chronic ligament ruptures. Acta Chir Scand 1966; 132: 551-565. 42 Andersen E, Hvass I. Treatment of the lateral instability of the ankle: a new modification of the Evans repair. Arch Orthop Trauma Surg 1986; 106: 15-17. 43 St Pierre R, Allman F, Basset FH et aL A review of lateral ankle ligamentous reconstructions. Foot Ankle 1982; 2: 114-123. 44 Visser HJ, Oloff LM, Jacobs AM. Lateral ankle stabilisation procedures: criteria and classification. J Bone Joint Surg 1980; 2: 74-84. 45 Brunner R, Gaechter A. Repair of fibular ligaments: comparison of reconstructive techniques using plantaris and peroneal tendons. Foot Ankle 1991; 11: 359-367. 46 Draenert K, Muller ME. Morphology and clinical aspect of the lateral ligaments of the ankle joint. Anal Anz 1980; 2: 188-200. 47 Karlsson J, Eriksson BL, Bergsten T et al. Comparison of two anatomic reconstructions for chronic lateral instability of the ankle joint. Am J Sports Med 1997; 11: 48-53.
© 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 71-76
4:71-76
Lateral ligament reconstruction of the ankle: comparative study of peroneus brevis tenodesis versus periosteal ligamentoplasty C. MABIT, J.M. C H A U D R U C , F. F I O R E N Z A , H. H U C A N D C. P E C O U T Department of Orthopaedic Surgery, Dupuytren's Hospital, University of Limoges, France
Summary Lateral chronic instability of the ankle represents 10-30% of ankle sprain sequelae. This study compares the results of two procedures: peroneus brevis tenodesis (PBT) and periosteal flap graft (PFG). The two series were composed by: 24 PBT, 22 PFG; all patients practised sports and 59% were competitors. The mean follow-up is 5.5 years for the PBT and 3 years for the PFG. The results were evaluated both clinically (according the functional rating scale of Good-Jones-Livingstone) and radiologically with pre- and postoperative stress tests (talar tilt, anterior drawer test). Sports resumption evaluation was also recorded. These results show better functional outcome for the periosteal procedure (91% success rate) compared to the peroneus brevis procedure (54% success rate). Functional results were statistically correlated (Fischer's test) with stability improvement evaluated on radiological stress test. Clinical outcome discrepancies may be explained by a biomechanical perspective: anatomical reconstructive procedure of the anterior talofibular ligament is a better technique to preserve the talar joint adaptative function.
Keywords: ankle instability; ankle lateral ligament reconstruction; periosteal ligamentoplasty; peroneus brevis tenodesis
Introduction Lateral ankle sprain is a common injury. It has been estimated that there is about one inversion injury of the ankle per 10 000 persons per day [1]. Ankle sprains account for 25-50% of injuries in sports and athletics [2--4]. Chronic lateral ankle instability represents 10-30% [5-7] of ankle sprain sequellae which can
Correspondence: Professor C. Mabit, Service d'Orthop6die Traumatologie, Centre Hospitalier Universitaire Dupuytren, 2, Av. Martin Luther King, 87042Limoges,France.
© 1998 BlackwellScienceLtd
severely impair sports performance. This type of instability implies lesions of the fibular lateral ligament complex and specifically the anterior talofibular ligament which acts as the primary restraint for the ankle at all angles of flexion [8, 9]. Mechanical and functional instability may be parallel phenomena but they are not strictly correlated [6, 10]. More than 50 reconstructive procedures for ankle ligamentoplasty have been described using: direct suture or reinsertion of torn ligaments; capsular shift [11-14]; ligamentoplasties with the peroneus brevis tendon [3, 15-18]; the inferior retinaculum extensor 71
C. MABIT ET AL.
72
20 151
~]~, ~
10
:':':[:.
5
L-St>L! ,?p-
:[:-5
Recreational Soccer
Tennis
Jude
Basket
Athletics Gymnastics
Sport
Figure 1 Sporting activities.
2
'
1
Figure 2 Peroneus brevis ligamentoplasty (Castaing procedure). The peroneus brevis tendon is passed through the transmalleolar antero-posterior tunnel and sutured to itself. (1) Inferiorextensor retinaculum. (2) Peroneus brevis. (3) Peroneus longus. (4) Transmalleolartunnel.
[19]; the plantaris tendon [5, 20]; the Achille's tendon [21], or the peroneus tertius [22]. The aim of this retrospective study is to compare two procedures: (1) a tenodesis with the peroneus brevis tendon (PBT) as described by Castaing [15, 23]; (2) an anatomical reconstruction of the anterior talofibular ligament with a periosteal flap graft (PFG) [24] which has recently gained popularity [25-29]. Materials
and methods
Patients This retrospective study includes 46 patients who underwent lateral ligamentous reconstructive procedures of the ankle. Twenty-four consecutive patients (15 men and nine women) aged 15-44 years (mean 27), were treated
with PBT. The mean delay between the initial episode of ankle sprain and the operation was 4 years (range, 3 months-15 years). Thirteen patients practised competition sports and 11 recreational sports. Twenty-two consecutive patients (13 men and nine women) aged 14-41 years (mean 21), were treated with PFG. The mean delay between the initial injury and the operation was 6 years (range, 2 months-17 years). Fourteen patients practised competition sports and eight recreational sports. The majority of the patients recalled several ankle sprains (a mean of 3) leading to chronic instability and functional impairment in athletic activities a n d / o r social life. Soccer was the most frequently concerned sport (Figure 1). There was no difference in the treatment of the initial accident between the two groups: for the majority of cases, initial treatment included plaster cast (with a mean duration of immobilization of 3 weeks) followed by a rehabilitation programme. However, a remarkable number of ankle sprains remained medically untreated (19/46).
Surgical protocols Peroneus
brevis
tendon.
A conventional lateral approach is used: the peroneus brevis is released and severed in its proximal part so as to free the distal 15cm of the tendon (the muscular part is sutured to the peroneus longus). Then a tunnel is drilled perpendicularly in the distal part of the lateral malleolus. The tendon is passed from back to front in this tunnel and sutured to itself with the foot in neutral position. The sutures are progressively tightened so as to obtain an optimal tension of the graft (Figure 2).
Periosteal flap graft. The procedure is performed through a lateral approach with a more proximal extension. Care should be taken with the superficial fibular nerve. The lateral malleolus and the neck of the talus are then exposed. The fibular periosteum is dissected with a rasp to at least l c m width and 12cm length, then a tunnel is vertically drilled through the talar neck. The graft is secured by a suture at its distal insertion to the periosteum of the anterior border of the lateral malleolus. The graft is then © 1998 BlackwellScience Ltd,Footand Ankle Surgery,4, 71-76
LATERAL LIGAMENT
RECONSTRUCTION
OF THE ANKLE
73
Table 2
Functional results
3
1
PBT group~
PFG groupJ-
7 6 8 3
10 10 0 2§
Grade 1 Grade 2 Grade 3 Grade 4
Mean follow-up: 5.5 years. ~-Mean follow-up: 3 years. § One failure after a secondary traumatic rupture in a soccer player who had fully resumed sports. Figure 3
Periosteal ligamentoplasty (Roy-Camille-Saillant procedure). The periosteal flap is individualized; its distal malleolar insertion is preserved. The graft is then passed through the transosseous tunnel drilled in the talar neck and sutured to itself. The anterior talofibular ligament is restored in an anatomical position. (1) Inferior extensor retinaculum. (2) Periosteal flap graft. (3) Transosseus tunnel drilled in talar neck. Table 1
Good-Jones-Livingstone Grading System of lateral ligament instability Grade
Description
Full activity, including strenuous sports. No pain, swelling or giving way. Occasional aching, only after strenuous exercise. No giving way or feeling of apprehension. No giving way but some remaining apprehension, especially on rough ground. Recurrent instability and giving way in normal activities, with episodes of pain and swelling.
p a s s e d t h r o u g h the talar tunnel and s u t u r e d to itself w i t h the foot in neutral position (Figure 3). For b o t h procedures, p o s t o p e r a t i v e i m m o b i l i z a t i o n is achieved t h r o u g h a leg brace for 5 weeks; w e i g h t bearing on crutches is authorized for at least 3 weeks. Then a rehabilitation p r o g r a m m e is initiated w h i c h incorporates not only the usual elements of physical therapy, such as strength a n d flexibility, b u t also activities to enhance p r o p r i o c e p t i o n a n d n e u r o m u s c u l a r control.
Methods
Results h a v e b e e n e v a l u a t e d b o t h clinically a n d radiographically. In order to standardize the results for c o m p a r a t i v e studies, the functional g r a d i n g s y s t e m established by G o o d et al. [30] (Table 1) a n d p r e v i o u s l y u s e d b y Sefton et al. [31] has b e e n used. © 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 71-76
Stiffness w a s also recorded: an i m p a i r m e n t of 10 ° or m o r e in the r a n g e of m o t i o n (ROM) w a s considered to be significant. R e s u m p t i o n of sport w a s also evaluated b y the n u m b e r of patients returning to a competitive level of practice. Comparative and postoperative radiologicat findings w e r e b a s e d on s t a n d a r d or intensified i m a g e s and stress r a d i o g r a p h s (talar tilt a n d anterior d r a w e r tests) w e r e p e r f o r m e d manually. Statistical correlation of functional and r a d i o g r a p h i c results w a s carried out b y the Fischer test.
Results
Follow-up r a n g e d f r o m 1 to 15 years with a m e a n of 5.5 years for PBT, a n d f r o m 1 to 4 years w i t h a m e a n of 3 years for PFG.
Clinical results
The overall results in the PBT g r o u p w e r e excellent in seven ankles (grade 1), g o o d in six (grade 2), fair in eight (grade 3) a n d p o o r in three (grade 4). In the PFG group, the result ratings w e r e excellent in 10 ankles, g o o d in 10 a n d p o o r in t w o (Table 2). Seventeen patients w h o u n d e r w e n t PBT s h o w e d significant (_> 10 °) loss in R O M as c o m p a r e d to only two patients treated b y PFG. H o w e v e r , in this series ROM is not statistically correlated w i t h clinical results. Sports r e s u m p t i o n evaluation s h o w e d that 45.5% of the patients w h o u n d e r w e n t PFG r e s u m e d their
74
C. M A B I T E T A L .
t-
r-
'~ n
3 "
J3-
Same level
Inferior level
II
Stop personal reasons
Same level
Stop ankle disability
Resumption of sport Figure 4
Functional results of periosteal flap graft. I , competitive sport; D, recreational sport.
Inferior level
Stop personal reasons
Stop ankle disability
Resumption of sport Figure 5
Functional results of peroneus brevis tenodesis. II, competitive sport; El, recreational sport. Table 3
s p o r t i n g activities at the s a m e level (Figure 4) while o n l y 29% of the patients w h o h a d PBT w e r e able to r e s u m e their activities (Figure 5). Two patients (9%) f r o m the PFG g r o u p c o u l d n o t r e s u m e sports d u e to persistant ankle p a i n or instability versus 11 patients (45.8%) in the PBT g r o u p . The PBT series results w e r e c o m p l i c a t e d b y three r u p t u r e s of the transplant, f o u r cases of severe loss of articular mobility, t w o n e u r o m a of the sural n e r v e a n d one a l g o d y s t r o p h i c s y n d r o m e . The PFG series results w e r e c o m p l i c a t e d b y t w o r u p t u r e s of the transplant. In the first case of failure, the periosteal graft w a s said to be ' w e a k ' o n the surgical report; the s e c o n d one w a s a s e c o n d a r y t r a u m a t i c r u p t u r e in a soccer p l a y e r w h o h a d fully r e s u m e d sports.
Radiological results
L o n g - t e r m stress r a d i o g r a p h s s h o w e d better results for the PFG l i g a m e n t o p l a s t y series w i t h n o case of
Radiological results (laximetry) Laximetry
Talar tilt <5° 5°-10 ° 10°-15° >15° Not done Anterior drawer test <8mm 8-15mm >15mm Not done
PBT group
PFG group
Preop
Postop
Preop
Postop
0 6 12 6 0
12 7 4 1 0
0 6 13 3 0
17 3 0 0 2
0 13 6 5
9 12 3 0
0 13 4 5
20 0 0 2
increased talar tilt (>10 °) or increased anterior d r a w e r test ( > 8 m m ) versus five patients (21%) a n d 15 p a t i e n t s (62.5%) in the PBT series, respectively. A g o o d functional result is statistically correlated (Fischer's test), w i t h a talar tilt <5 ° (P<0.01) a n d an anterior d r a w e r test < 8 m m (P<0.02) (Table 3). © 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 71-76
LATERAL LIGAMENT
O n e case w i t h osteoarthritic c h a n g e w a s r e p o r t e d in the PBT g r o u p .
Discussion T h e m o s t w i d e l y p e r f o r m e d p r o c e d u r e s in the past have been non-anatomic reconstructions with tenodesis u s i n g the p e r o n e u s brevis [16-18, 32-35]. M a n y studies h a v e s h o w n g o o d s h o r t - t e r m results, b u t the l o n g - t e r m results h a v e d e t e r i o r a t e d w i t h time, especially in y o u n g athletes. A n a t o m i c a l reconstructions, w i t h or w i t h o u t augmentation, have been chosen by many authors d u r i n g recent y e a r s b e c a u s e of the b i o m e c h a n i c a l a n d clinical d r a w b a c k s w i t h n o n - a n a t o m i c t e c h n i q u e s [2, 28, 36-39]. I n the p r e s e n t study, the overall o u t c o m e of the c o m p a r i s o n b e t w e e n the t w o p r o c e d u r e s t e n d s to f a v o u r PFG. As stated b y several a u t h o r s [8, 23, 39], better f u n c t i o n a l results are correlated w i t h a n a t o m ical r e c o n s t r u c t i v e p r o c e d u r e s . The R O M w a s m o r e o f t e n felt to be d i s t u r b e d after p e r o n e a l tenodesis. These o b s e r v a t i o n s are c o n f i r m e d b y f o r m e r l y p u b l i s h e d d a t a [40-43]. Visser et aI. [44] h a v e r e p o r t e d t h a t limitation of the R O M after tenodesis w a s n o t infrequent. B r u n n e r a n d G a e c h t e r [45], R o y Camille et al. [27], Visser et al. [44], D r a e n e r t a n d M(iller [46] a n d K a r l s s o n et al. [47] stress that a n a t o m i c a l l y accurate t e c h n i q u e s of l i g a m e n t o u s r e c o n s t r u c t i o n are m o r e closely linked w i t h p r e s e r v e d R O M a n d g o o d stability of the ankle joint. Biomechanically, these t w o t y p e s of r e c o n s t r u c t i o n are v e r y different. PBT uses graft material ( p e r o n e u s brevis t e n d o n ) s e c u r e d in a n o n - a n a t o m i c a l position, t h e r e b y e r a d i c a t i n g a n active stabilizer of the ankle a n d l o c k i n g the sub-talar joint. PFG is an a n a t o m i c a l r e c o n s t r u c t i o n w h i c h p r e s e r v e s the lateral active stabilizers of the ankle. The success of this t y p e of r e c o n s t r u c t i o n relies o n the quality of the periosteal graft, w h i c h varies a c c o r d i n g to age, sex a n d m o r p h o t y p e [26]. O n the basis of an isometric p o s i t i o n i n g of ligaments insertion, as u s u a l l y a c c e p t e d in k n e e surgery, w e h a v e b e g u n a p r e l i m i n a r y stt~dy e v a l u a t i n g a n original graft p r o c e d u r e u s i n g the p e r o n e u s tertius t e n d o n . Initial result s h o w e q u i v a l e n t a n a t o m i c a l a n d b i o m e c h a n i c a l a d v a n t a g e s b u t require f u r t h e r clinical e v a l u a t i o n [22]. © 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 71-76
RECONSTRUCTION
OF THE ANKLE
75
Conclusion O n the basis of these results, a n a t o m i c a l reconstruction can be r e c o m m e n d e d : it is e a s y to p e r f o r m , has a l o w rate of c o m p l i c a t i o n a n d gives satisfactory m e c h a n i c a l stability. I n o u r series, PFG has p r o d u c e d a 91% success rate o v e r a 3 y e a r s follow-up, a n d PBT has a 54% success rate. In y o u n g athletes, better functional results c a n be e x p e c t e d w i t h a n a t o m i c a l r e c o n s t r u c t i o n at follow-up.
References 1 Brooks SC, Potter BT, Rainey JB. Treatment for partial tears of the lateral ligament of the ankle: a prospective trial. Br Med J 1981; 282: 606-607. 2 Balduini F, Vergso JJ, Torg JS, Torg E. Management and rehabilitation of ligamentous injuries to the ankle. Sports Med 1987; 4: 364-380. 3 Garrick JG. The frequency of injury, mechanism of injury and epidemiology of ankle sprains. Am J Sports Med 1977;5: 241-242. 4 Mack RP. Ankle injuries in athletes. Clin Sports Med 1982; 1: 71-84. 5 Anderson ME. Reconstruction of the lateral ligaments of the ankle using the plantaris tendon. J Bone Joint Surg 1985; 67A: 930-934. 6 Freeman M, Dean M, Hanham I. The etiology and prevention of functional instability of the foot. ] Bone Joint Surg 1965; 47B: 678-685. 7 Peters JW, Trevino SG, Renstrom P. Chronic lateral ankle instability. Foot Ankle 1991; 12: 182-191. 8 Burks RT, Morgan J. Anatomy of the Idteral ankle ligaments. Am J Sports Med 1994; 22: 72-77. 9 Johnson E, Marklof KL. The contribution of the anterior talofibular ligament to ankle laxity. J Bone Joint Surg 1983; 65A: 81-88. 10 Tropp H. Functional instability of the ankle joint. Medical Dissertation. LinkOping University, 1985. 11 Blancher A. La r6fection capsuloqigamentaire dans les instabilit6s chroniques de la tibio-tarsienne. Rev Chir Orthop 1975; 61 (Suppl 2): 175-176. 12 Christet P, Witwoet J, Jaulin P. Traitement chirurgical des instabilit6s tibio-tarsiennes chroniques chez le sportif par retention transosseuse du plan capsulo-ligamentaire externe: propos de 28 cas. J Traumatol Sport 1988; 5: 177-184. 13 Duquennoy A, Fontaine C, Martinot JC et aL Instabilit6 chronique de l'articulation tibio-tarsienne remise en tension ligamentaire externe: apropos de 58 cas revus. Rev Chit Orthop 1989; 75: 387-393. 14 Gould N. Repair of lateral ligament of the ankle. Foot Ankle 1987; 2: 55-58. 15 Castaing J, Le Chevalier PL, Meunier M. Entorse ~ r6p6tition ou subluxation r6cidivante de la tibio-tarsienne: une technique simple de ligamentoplastie externe. Rev Chir Orthop 1961; 47: 598-608. 16 Christman OD, Snook GA. Reconstruction of lateral ligaments 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 1969; 51A: 904-912.
76
C. MABIT
ET AL.
17 Evans DL. Recurrent instability of the ankle: a method of surgical treatment. J R Soc Med 1953; 46: 343-344. 18 Watson-Jones R. Fractures and Joint Injury, Vol. 2, 4th edn. Baltimore: Williams & Wilkins, 1955. 19 Segal P, Dehoux E, Deprey F et al. Le traitement chirurgical des laxit6s externes chroniques de la cheville par ligamentoplastie au frondiforme. J Traumatol Sport 1991; 8: 24-27. 20 Weber BG, Hupfauer W. Zur Behandlung der frischen fibularen Bandruptur und der chronischen fibularen Bandinsuffizienz. Archiv Orthop Unfallchir 1969; 65: 215. 21 Solheim L, Denstad T. Chronic lateral instability of the ankle: a method of reconstruction using the Achilles tendon. Acta Orthop'Sca~d 1980; 51: 193-196. 22 Mabit C, Pecout C, Arnaud JP. La ligamentoplastie au troisi6me fibulaire (p6roneus tertius) dans les laxit6s lat6rales de la cheville: tect~ique chirurgicale. Rev Chir Orthop 1996; 82: 70-75. 23 Castaing J, Falaise B, Burdin P. Ligamentoplastie au court p6ronier lat6ral dans le traitement des instabilit6s chroniques de la cheville: r6vision a long terme. Rev Chir Orthop 1984; 70: 653-656. 24 Katzenstein M. Die plastische Bildung von Gelenkbandern. Med Klin 1924; 19: 1392-1395. 25 Kuner EH. Der gestielte Periostztigel als M6glichkeit des Augenbandersatzes. Hefte Unfallheilk 1978; 133: 191-193. 26 Mabit C, Setton D, Charissoux JL et al. La ligamentoplastie au p6rioste dans les instabilit6s chroniques de la cheville chez le sportif. J Traumatol Sport 1993; 10: 102-105. 27 Roy-Camille R, Saillant G, Gagna G, Benazet JP, Feray C. Les laxit6s externes chroniques de la cheville: cure chirurgicale par une ligamentoplastie au p6rioste. Rev Chir Orthop 1986; 72: 121-126. 28 Sjolin SU, Dons-Jensen H, Simonsen O. Reinforced anatomical reconstruction of the anterior talo-fibular ligament in chronic anterolateral instability using a periosteal flap. Foot Ankle 1991; 12: 15-18. 29 Wirth CJ. Die modifizierte Periostlappenplastik nach Kuner bei chronischer Instabilitat des fibularen Kapsel-Band-Apparates. Operat Orthop Traumatol 1991; 3: 196-202. 30 Good CJ, Jones MA, Livingstone BN. Reconstruction of the lateral ligament of the ankle injury. 1975; 7: 63-65.
31 Sefton GK, George J, Fitton JM, McCullen H. Reconstruction of the anterior talofibular ligament for the treatment of the instable ankle. J Bone Joint Surg 1979; 61B: 352-354. 32 Barbari SG, Brevig K, Egge T. Reconstruction of the lateral ligamentous structures of the ankle with a modified Watson-Jones procedure. Foot Ankle 1987; 6: 362-368. 33 Elmslie RC. Recurrent subluxation of the ankle joint. Ann Surg 1934; 100: 364-367. 34 Lee HG. Surgical repair in recurrent dislocation of the ankle joint. J Bone Joint Surg 1957; 39A: 828-834. 35 Liu SH, Baker CL. Comparison of lateral ankle ligamentous reconstruction procedures. Am J Sports Med 1994; 22: 313-317. 36 Gould N. Early and late repair of lateral ligament of the ankle. Foot Ankle 1980; 1: 84-89. 37 Hamilton WG, Thompson FM, Snow SW. The modified Brostr6m procedure for lateral ankle instability. Foot Ankle 1993; 14: 1-7. 38 Karlsson J, Bergsten T, Lansinger O et aL Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg 1988; 70A: 581-588. 39 LOfvenberg R, Karrholm J, Ahlgren O. Ligament reconstruction for ankle instability: a 5-year prospective RSA follow-up of 30 cases. Acta Orthop Scand 1994; 65: 401-407. 40 Vainiopaa S, Kirves P, Laike E. Lateral instability of the ankle and results when treated by the Evans procedure. Am J Sports Med 1980; 8: 437-439. 41 Brostrom L. Sprained ankles. VI: Surgical treatment of chronic ligament ruptures. Acta Chir Scand 1966; 132: 551-565. 42 Andersen E, Hvass I. Treatment of the lateral instability of the ankle: a new modification of the Evans repair. Arch Orthop Trauma Surg 1986; 106: 15-17. 43 St Pierre R, Allman F, Basset FH et aL A review of lateral ankle ligamentous reconstructions. Foot Ankle 1982; 2: 114-123. 44 Visser HJ, Oloff LM, Jacobs AM. Lateral ankle stabilisation procedures: criteria and classification. J Bone Joint Surg 1980; 2: 74-84. 45 Brunner R, Gaechter A. Repair of fibular ligaments: comparison of reconstructive techniques using plantaris and peroneal tendons. Foot Ankle 1991; 11: 359-367. 46 Draenert K, Muller ME. Morphology and clinical aspect of the lateral ligaments of the ankle joint. Anal Anz 1980; 2: 188-200. 47 Karlsson J, Eriksson BL, Bergsten T et al. Comparison of two anatomic reconstructions for chronic lateral instability of the ankle joint. Am J Sports Med 1997; 11: 48-53.
© 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 71-76