- Email: [email protected]
Reconstruction of the lateral ligament of the ankle
Injury.
63
7, 63-65
Reconstruction of the lateral ligament of the ankle C. J. Good, M. A. Jones and B. N. Livingstone Department
of Orthopaedic
Surgery, Orpington Hospital
Summary
An operation for the treatment of chronic inversion instability of the ankle is described and the results are reported. It is suggested that this operation is considered in all patients with this syndrome, in whom conservative measures have failed. SEVERAL operative techniques are available for the correction of recurrent ligament instability of the ankle joint. The methods described by Evans (1953) and Watson-Jones (1955) both utilize the tendon of peroneus brevis, whilst Elmslie’s operation (1934) can be performed with either peroneus brevis or a free fascia lata graft. To perform the Watson-Jones operation, a sufficient length of tendon may not be available without extensive exposure. Furthermore, it has been reported that inversion may not be restricted for long (Anderson and LeCocq, 1954). In this study 22 patients were treated by a modification of the Evans procedure and the results are reviewed.
INDICATIONS
FOR
OPERATION
There were 22 patients on whom 25 operations were performed. All were primary reconstructive procedures and no patient had undergone previous surgery to the ankle. The age of the patients ranged from 12 to 60 with a mean of 25. All had symptoms of recurrent instability (’ giving way ‘), pain and swelling, with demonstrable laxity of the lateral ligament. The duration of symptoms varied from 2 months to 42 years. All had lost time from work or school because of instability and had undergone conservative treatment for at least 6 weeks. This treatment included peroneal exercises, faradism and the provision of a lateral ‘ float-out ’ heel. With the exception of one patient with rheumatoid disease,
every patient gave a definite which predated the symptoms.
OPERATIVE
history
of trauma
TECHNIQUE
The limb is exsanguinated with a tourniquet. A curved lateral incision is made commencing approximately 4 in above the lateral malleolus, running behind it and then extending forwards, towards the base of the fifth metatarsal. The peroneal tendons are exposed, and care is taken to raise the skin flaps with as much underlying soft tissue as possible. Peroneus brevis is identified and its tendon freed from its muscle belly, leaving the lower end attached to the base of the fifth metatarsal. An oblique channel is drilled in the lower end of the fibula from the digital fossa, upwards and backwards, using graduated drills of & in, G in The upper and $ in. in diameter sequentially. end of the divided peroneus brevis tendon is passed through this channel from below and doubled over the lateral aspect of the fibula. It is then sutured to itself in as tight a position as possible whilst the foot is held in maximum eversion. The remaining proximal portion of peroneus brevis muscle belly is sutured to the peroneus longus tendon, to retain the function of the former muscle (Fig. 1). Stability is tested by manual inversion, which should be impossible. Fat and skin are sutured, a pressure bandage applied before the tourniquet is released and, finally, with the tourniquet off, a plaster cast is applied to hold the foot in eversion and dorsiflexion. After operation the foot is elevated for 14 days, after which time sutures are removed and a belowknee walking plaster is applied for a further 4 weeks. Active plantar and dorsiflexion exercises
64
injury: the British Journal of Accident Surgery Vol. ~/NO. 1
are given thereafter until a ment has been achieved. from this rkgime has been in healing, when the patient bearing with a removable healing has occurred.
full range of moveThe only deviation cases of poor wound remains non-weight plaster slab until
Table /. Grading of symptoms in lateral ligament instability of the ankle Grade 1 Grade 2
Grade 3
Grade 4
Full activity, including strenuous sport. No pain, swelling or giving way Occasional aching only following strenuous exercise. No giving way or feeling of apprehension No giving way but some remaining apprehension and takes care when walking on rough ground Recurrent instability and giving way in normal activities, with episodes of pain and swelling
2. Ankle movements--every patient regained a full range of movement after operation. 3. Scar-the resulting scar was judged to be good in 16 patients and only in 2 were the scars unsightly.
Complications
Fig. 1. A schematic drawing of the reconstruction operation. (A) Peroneus longus muscle belly. (B) Peroneus brevis muscle belly sutured to (D) Peroneus longus tendon. (C) Peroneus brevis tendon passed through the channel drilled in the fibula and sutured back to itself. RESULTS Patients were assessed for symptoms in 4 grades according to level of activity, recurrent instability, feeling of apprehension, and pain (Table I). All patients were in grade 4 before operation. All ankles were examined for stability, range of movements and scar appearance. The duration of follow-up ranged from 4 months to 34 years. Symptoms Results are summarized in Table II. All patients were able to return to their normal occupations after operation. One, who had undergone bilateral operations, was able to play 2 games of football in a weekend without symptoms 2 years after operation. Examination 1. Clinical stabilityAvery clinically stable to manual
reconstruction testing.
was
General complications, such as deep-vein thrombosis, have not been encountered. Wound healing was delayed in 6 patients. Of these, one required secondary suture, one, a patient with rheumatoid disease on corticosteroids, required a split-skin graft, and the remaining 4 healed after dressings alone. One patient, who attained only a grade 3 result, was a young girl with a clear history of trauma, in whom reconstruction of the lateral ligament should have given a good result. Tab/e II. Relief of symptoms after reconstruction of the lateral ligament of the ankle Grade
No. of cases
1 2 3 4
11 13 1 0 25 (In 22 patients)
However, as a result of too anterior a drilling of the fibular channel, the reconstructed ligament tended to dislocate forwards on ankle movement. Despite this the ankle was stable. DISCUSSION Freeman (1965) studied a large series of patients with chronic inversion instability of the ankle. He showed that the finding of abnormal varus tilt of the talus on stress radiographs did not
Good et al. : Lateral Ligament
65
correlate with functional instability of the ankle. He further found that in many patients with functional instability, no clinical or radiological abnormalities could be demonstrated. This led him to conclude that injury to the ligaments might be accompanied by disruption of the proprioceptive mechanoreceptor nerve fibres in the joint, thus causing incoordination of the muscles normally maintaining stability. We would agree that radiological measurement of talar tilt is unnecessary for the diagnosis of lateral ligament instability, and that a positive history together with clinical evidence of lateral ligament laxity are sufficient criteria. The operation described creates a static block to ankle inversion and may obviate the need for an intact proprioceptive system, as opposed to Evans’ procedure, which re-routes the tendon in a dynamic situation. Acknowledgement We would like to express Requests./&- reprints should be
our gratitude
to Mr
addressed to: Mr C. J. Good,
Orpington
S. J. S. Lam, FRCS for allowing us to study these patients, who were under his care.
REFERENCES
ANDERSONK. J. and LECOCQ J. F. (1954) Operative treatment of injury to the fibular collateral ligament of the ankle. J. Bone Joint Surg. 36A, 825. ELMSLIER. C. (1934) Recurrent subluxation of the ankle joint. Ann. &rg. 100,364. EVANSD. L. (1953) Recurrent instabilitv of the ankle. A method-of surgical treatment. hoc. R. Sot. Med. 46, 343.
FREEMANM. A. R. (1965) Instability of the foot after injuries to the lateral ligament of the ankle. J. Bone Joint Surg. 47E%,669.
FREEMANM. A. R., DEAN M. R. E. and HANHAM I. W. F. (1965) The aetiology and prevention of functional instability of the foot. J, Bone Joint Surg. 47B, 678. WA&N-JONES SIR R. (1955) Fractures and Joint Injuries. 4th ed. vol. 2, p. 821. Edinburgh and London, E. & S. Livingstone. Hospital,
Orpington,
Kent.
63
7, 63-65
Reconstruction of the lateral ligament of the ankle C. J. Good, M. A. Jones and B. N. Livingstone Department
of Orthopaedic
Surgery, Orpington Hospital
Summary
An operation for the treatment of chronic inversion instability of the ankle is described and the results are reported. It is suggested that this operation is considered in all patients with this syndrome, in whom conservative measures have failed. SEVERAL operative techniques are available for the correction of recurrent ligament instability of the ankle joint. The methods described by Evans (1953) and Watson-Jones (1955) both utilize the tendon of peroneus brevis, whilst Elmslie’s operation (1934) can be performed with either peroneus brevis or a free fascia lata graft. To perform the Watson-Jones operation, a sufficient length of tendon may not be available without extensive exposure. Furthermore, it has been reported that inversion may not be restricted for long (Anderson and LeCocq, 1954). In this study 22 patients were treated by a modification of the Evans procedure and the results are reviewed.
INDICATIONS
FOR
OPERATION
There were 22 patients on whom 25 operations were performed. All were primary reconstructive procedures and no patient had undergone previous surgery to the ankle. The age of the patients ranged from 12 to 60 with a mean of 25. All had symptoms of recurrent instability (’ giving way ‘), pain and swelling, with demonstrable laxity of the lateral ligament. The duration of symptoms varied from 2 months to 42 years. All had lost time from work or school because of instability and had undergone conservative treatment for at least 6 weeks. This treatment included peroneal exercises, faradism and the provision of a lateral ‘ float-out ’ heel. With the exception of one patient with rheumatoid disease,
every patient gave a definite which predated the symptoms.
OPERATIVE
history
of trauma
TECHNIQUE
The limb is exsanguinated with a tourniquet. A curved lateral incision is made commencing approximately 4 in above the lateral malleolus, running behind it and then extending forwards, towards the base of the fifth metatarsal. The peroneal tendons are exposed, and care is taken to raise the skin flaps with as much underlying soft tissue as possible. Peroneus brevis is identified and its tendon freed from its muscle belly, leaving the lower end attached to the base of the fifth metatarsal. An oblique channel is drilled in the lower end of the fibula from the digital fossa, upwards and backwards, using graduated drills of & in, G in The upper and $ in. in diameter sequentially. end of the divided peroneus brevis tendon is passed through this channel from below and doubled over the lateral aspect of the fibula. It is then sutured to itself in as tight a position as possible whilst the foot is held in maximum eversion. The remaining proximal portion of peroneus brevis muscle belly is sutured to the peroneus longus tendon, to retain the function of the former muscle (Fig. 1). Stability is tested by manual inversion, which should be impossible. Fat and skin are sutured, a pressure bandage applied before the tourniquet is released and, finally, with the tourniquet off, a plaster cast is applied to hold the foot in eversion and dorsiflexion. After operation the foot is elevated for 14 days, after which time sutures are removed and a belowknee walking plaster is applied for a further 4 weeks. Active plantar and dorsiflexion exercises
64
injury: the British Journal of Accident Surgery Vol. ~/NO. 1
are given thereafter until a ment has been achieved. from this rkgime has been in healing, when the patient bearing with a removable healing has occurred.
full range of moveThe only deviation cases of poor wound remains non-weight plaster slab until
Table /. Grading of symptoms in lateral ligament instability of the ankle Grade 1 Grade 2
Grade 3
Grade 4
Full activity, including strenuous sport. No pain, swelling or giving way Occasional aching only following strenuous exercise. No giving way or feeling of apprehension No giving way but some remaining apprehension and takes care when walking on rough ground Recurrent instability and giving way in normal activities, with episodes of pain and swelling
2. Ankle movements--every patient regained a full range of movement after operation. 3. Scar-the resulting scar was judged to be good in 16 patients and only in 2 were the scars unsightly.
Complications
Fig. 1. A schematic drawing of the reconstruction operation. (A) Peroneus longus muscle belly. (B) Peroneus brevis muscle belly sutured to (D) Peroneus longus tendon. (C) Peroneus brevis tendon passed through the channel drilled in the fibula and sutured back to itself. RESULTS Patients were assessed for symptoms in 4 grades according to level of activity, recurrent instability, feeling of apprehension, and pain (Table I). All patients were in grade 4 before operation. All ankles were examined for stability, range of movements and scar appearance. The duration of follow-up ranged from 4 months to 34 years. Symptoms Results are summarized in Table II. All patients were able to return to their normal occupations after operation. One, who had undergone bilateral operations, was able to play 2 games of football in a weekend without symptoms 2 years after operation. Examination 1. Clinical stabilityAvery clinically stable to manual
reconstruction testing.
was
General complications, such as deep-vein thrombosis, have not been encountered. Wound healing was delayed in 6 patients. Of these, one required secondary suture, one, a patient with rheumatoid disease on corticosteroids, required a split-skin graft, and the remaining 4 healed after dressings alone. One patient, who attained only a grade 3 result, was a young girl with a clear history of trauma, in whom reconstruction of the lateral ligament should have given a good result. Tab/e II. Relief of symptoms after reconstruction of the lateral ligament of the ankle Grade
No. of cases
1 2 3 4
11 13 1 0 25 (In 22 patients)
However, as a result of too anterior a drilling of the fibular channel, the reconstructed ligament tended to dislocate forwards on ankle movement. Despite this the ankle was stable. DISCUSSION Freeman (1965) studied a large series of patients with chronic inversion instability of the ankle. He showed that the finding of abnormal varus tilt of the talus on stress radiographs did not
Good et al. : Lateral Ligament
65
correlate with functional instability of the ankle. He further found that in many patients with functional instability, no clinical or radiological abnormalities could be demonstrated. This led him to conclude that injury to the ligaments might be accompanied by disruption of the proprioceptive mechanoreceptor nerve fibres in the joint, thus causing incoordination of the muscles normally maintaining stability. We would agree that radiological measurement of talar tilt is unnecessary for the diagnosis of lateral ligament instability, and that a positive history together with clinical evidence of lateral ligament laxity are sufficient criteria. The operation described creates a static block to ankle inversion and may obviate the need for an intact proprioceptive system, as opposed to Evans’ procedure, which re-routes the tendon in a dynamic situation. Acknowledgement We would like to express Requests./&- reprints should be
our gratitude
to Mr
addressed to: Mr C. J. Good,
Orpington
S. J. S. Lam, FRCS for allowing us to study these patients, who were under his care.
REFERENCES
ANDERSONK. J. and LECOCQ J. F. (1954) Operative treatment of injury to the fibular collateral ligament of the ankle. J. Bone Joint Surg. 36A, 825. ELMSLIER. C. (1934) Recurrent subluxation of the ankle joint. Ann. &rg. 100,364. EVANSD. L. (1953) Recurrent instabilitv of the ankle. A method-of surgical treatment. hoc. R. Sot. Med. 46, 343.
FREEMANM. A. R. (1965) Instability of the foot after injuries to the lateral ligament of the ankle. J. Bone Joint Surg. 47E%,669.
FREEMANM. A. R., DEAN M. R. E. and HANHAM I. W. F. (1965) The aetiology and prevention of functional instability of the foot. J, Bone Joint Surg. 47B, 678. WA&N-JONES SIR R. (1955) Fractures and Joint Injuries. 4th ed. vol. 2, p. 821. Edinburgh and London, E. & S. Livingstone. Hospital,
Orpington,
Kent.