Introduction

Because it generally is agreed that most acute lateral ankle sprains can be treated nonoperatively while acknowledging an incidence of late problems in 10% to 20% it is no surprise that lateral ankle ligament reconstruction is commonplace.¹ This approach to the treatment of lateral ankle sprains is reasonable only if reconstructive procedures for the lateral ankle ligaments can be as successful as primary repair. Recent consensus of orthopaedic opinion supports this viewpoint. However, there is still controversy that persists regarding the best method of treatment of acute lateral ankle sprains because of the paucity of scientific studies in this field that meet the requirements for proof of method in outcomes-based research.²

Most patients with chronic lateral ankle sprains and instability present with either recurrent ankle sprains after an initial acute sprain or with the feeling of looseness in the ankle and the sensation of “giving way.” These patients may complain of ankle pain, but it is not a prerequisite feature of this problem, although the examination confirms the presence of a positive anterior drawer test and/or a positive inversion stress test. Tenderness may be present, but often is more indicative of associated pathology, as noted later. The examiner must be thorough enough to rule out other sources of symptoms (Table 13-1) because the clinical diagnosis of chronic lateral ankle instability has been associated with the intraoperative findings of peroneal tendon pathology (tenosynovitis, tears, dislocation), anterolateral impingement lesions, ankle synovitis, intraarticular loose bodies, talar osteochondral lesions, and medial ankle tenosynovitis.³ A comprehensive physical therapy program should be initiated first. Symptoms often will resolve with correction of the deficits in proprioception, strength, and flexibility. Regardless, therapy can improve the results in patients who ultimately require surgery. The nonoperative treatment also includes activity and/or shoe modification (e.g., lateral heel wedge), an ankle-foot orthosis, and/or orthotic devices incorporating a lateral heel wedge. Brostrom⁴ found that symptoms of instability remained in 20% of his patients who were treated in a conservative fashion. Athletes may use a nonoperative approach to get through a season but rarely consider this an acceptable long-term solution unless their symptoms are minimal.

Table 13-1 Sources of Chronic Pain or Instability after Ankle Sprain

Surgical Treatment

Indications for surgical treatment include young to middle-aged, active individuals who have failed a well-designed, nonoperative treatment program. I use the radiographic criteria of an anterior drawer greater than 1 cm (or a side-to-side difference of >3 mm), and a talar tilt greater than 15 degrees (or a side-to-side difference of >10 degrees) as guidelines but have found that the symptoms and signs are most critical. An in-office mini C-arm is a convenient tool to confirm the radiographic instability. Contraindications to surgery include other causes of instability (collagen diseases, tarsal coalitions, neuromuscular diseases, neurologic disorders, or functional instability), older patients with sedentary lifestyles, patients with serious medical conditions that would preclude anesthesia and major surgery, circulatory impairment, presence of ongoing infection, lateral ankle pain without documented lateral instability, history of complex regional pain syndrome, or degenerative arthritis. A relative contraindication is failure of the patient to participate in a preoperative rehabilitation program.

The goals of a reconstruction or repair procedure are correction of instability, elimination of pain, and avoidance of surgical morbidity. Anatomic repair or reconstruction is preferable in restoring normal joint kinematics. If there is associated pathology present, it must be recognized and treated simultaneously. Inadequate local tissue to stabilize the ankle may dictate the use of a tendon transfer or tendon graft. Such occasions might include patients with known collagen disease, unusually large individuals (e.g., patients larger than 250 lb), or patients with a failure of a prior anatomic repair. Avoidance of nerve injury and preservation of ankle and subtalar joint motion are major factors in preventing morbidity when performing lateral ankle stabilization.

Diagnostic and surgical arthroscopy is warranted before ankle stabilization. Chondral injury is the most common problem discovered at arthroscopy, with almost 30% of acute ankle injuries and 95% of chronic ankles having this lesion in one study of an athletic population.⁵ A more recent study by Komenda and Ferkel⁶ found only a 25% incidence of chondral injury in their chronic ankle instability series. Regardless, the value of ankle arthroscopy, particularly in cases of chondral fracture, loose bodies, and soft-tissue impingement has been confirmed in several studies.^6–9 Hintermann and co-workers⁹ concluded that essential information was obtained by performing ankle arthroscopy at the time of surgery for ankle instability.

Operations for stabilization of the lateral ankle in cases of chronic instability are numerous. When instability persists despite conservative treatment, the surgeon can choose from more than 50 methods of reconstructing the lateral ankle ligaments. Fortunately, the reported short-term success rate is greater than 80% for all these procedures, according to the literature.¹⁰ The primary difference in the various procedures is whether or not they are designed to anatomically reconstruct the ligaments. In a manner reminiscent of the surgical history of shoulder and knee instability, more anatomic reconstructions are gaining popularity for ankle instability. This began with the introduction of the secondary repair of the previously injured ligaments by Lennart Brostrom in 1966.¹¹ It has taken almost four decades for the accumulation of scientific evidence to cast doubt on the tenodesis procedures described by Evans, Watson-Jones, Larsen, and Chrisman and Snook.^12–16 The following discussion focuses on the anatomic procedures, whether by direct repair in the tradition of Brostrom or by the use of tissue transfer or tissue grafts done through anatomically placed bone tunnels.

Brostrom described his anatomic repair as a delayed procedure for chronic lateral ankle instability. The procedure is a straightforward division and imbrication of the anterior talofibular ligament. The calcaneofibular ligament is not addressed. Various modifications have been described, the most popular being a reinsertion into a bony trough,¹⁷ imbrication of the calcaneofibular ligament,¹⁸ and reinforcement with the inferior extensor retinaculum.¹⁹ Other authors have described the use of different graft sources to rebuild the lateral ankle ligaments while emphasizing the anatomic placement of bone tunnels. Graft sources for this include the plantaris tendon,^20–22 the split peroneus brevis tendon,^23,24 hamstring tendons,^25–27 and allograft tendons.^28,29

Results

Results of the Brostrom anatomic reconstruction are excellent. In Brostrom’s original study, 51 of 60 patients demonstrated minimal or no instability at follow-up.¹¹ Other reported results from the Brostrom procedure or a modification thereof include large and small series of patients from around the world, with more than 500 cases reported and results ranging from 85% to 100% successful.^13,30–37 Lesser results are associated with heel varus, inadequate rehabilitation, nerve injury, preexisting arthritis, and significant repeat sprains.

Objective results of comparison studies that include anatomic procedures such as the Brostrom versus tenodesis procedures all favor the former procedure. In a cadaveric study comparing the Chrisman-Snook, Watson-Jones, and modified Brostrom procedures, the modified Brostrom procedure produced the least amount of talar tilt and anterior drawer translation, as well as having the greatest mechanical strength.³⁸ Another study, a prospective, randomized comparison of Chrisman-Snook and modified Brostrom, found that both procedures had greater than 80% good or excellent results, but there were more complications in the Chrisman-Snook group (five with wound problems, eight with sural nerve injury, and six with the feeling that the ankle was “too tight”). Brostrom complications were almost nonexistent and included no wound problems, no nerve injury, and only two with a feeling that the ankle was “too tight.”¹³ In a long-term, multicenter outcome study of anatomic reconstruction versus teno-desis, Krips and associates³⁹ found that more patients with tenodesis procedures had positive anterior drawer signs, medial ankle degenerative changes, higher mean talar tilt, and anterior talar translation. In addition, significantly fewer patients in the tenodesis group had excellent results, and more patients had a fair or poor result. In a follow-up study, patients who underwent tenodesis procedures underwent more revision procedures, demonstrated more osteoarthritis, more instability, tenderness, chronic pain, and limited dorsiflexion. Good to excellent results were found in 80% of patients at 30-year follow-up after anatomic reconstruction, versus only 33% after Evans tenodesis.⁴⁰ Overall, it appears that tenodesis procedures fail to restore the normal anatomy, resulting in lessened mechanical stability and a decrease in patient satisfaction. Because of these well-documented inherent problems of nonanatomic tenodesis procedures, anatomic ligamentous reconstruction is the preferable treatment approach in almost all circumstances.

Complications

Neurologic damage and wound complications are not infrequent. Injury to the superficial nerves is the most common complication following operative repair of the lateral ankle ligaments. Depending on the report and the type of surgical approach used, the incidence ranges from 7% to 19%.⁴¹ The sural nerve is at greater risk with tenodesis procedures.⁴² Wound dehiscence, superficial and deep infection, loss of ankle and/or subtalar motion, and deep venous thrombosis are less-often reported complications. Wise patient selection and good surgical technique are paramount in keeping these complications to a minimum.

Direct Ligament Repair (Modified Brostrom Procedure)

For most cases of chronic lateral ankle instability in the athletic population, a modified Brostrom technique is applicable. Its advantage is that it is an anatomic repair, with no tenodesis effect and no major change in the ankle and subtalar joint biomechanics. A second advantage is that it does not sacrifice adjacent healthy tissue. Indications include those patients with chronic lateral ankle ligament instability who are unresponsive to physical therapy. Contraindications include patients with structural varus deformities, previously failed lateral ligament reconstructions, genetic collagen disorders (Marfan’s and Ehlers-Danlos syndromes), or posttraumatic conditions with soft-tissue loss. Relative contraindications are obese patients (more than 250 lb) or patients whose instability exceeds 10 years duration with history of multiple severe sprains.¹⁷ For these patients, consideration is given to use a free tendon graft (allograft or autograft) for augmentation.

My operative technique includes planned day surgery or a 23-hour hospital stay. General, spinal, or regional anesthesia may be used. The patient is positioned supine with a bolster under the ipsilateral hip. A thigh tourniquet is placed. The procedure is performed through an anterior lateral incision paralleling the border of the fibula unless a more extensile longitudinal incision is necessary to address additional pathology.

Technique

1 The incision begins at the level of the plafond and extends distally to the level of the peroneal tendons (Fig. 13-1). The lateral branch of the superficial peroneal nerve and the sural nerve are protected.

2 Dissection is carried down to the capsule. To isolate the remaining portion of the anterior talofibular ligament (ATFL), it is helpful to enter the anterolateral capsule at the plafond level and carefully dissect distally to expose the ATFL fibers. If the ligaments appear stretched (Fig. 13-2) and there is no obvious rupture, the capsule and ligament are divided a few millimeters from their fibular origin and imbricated.

3 To locate the calcaneofibular ligament (CFL), the peroneal sheath is opened and the peroneal tendons are first checked for a tear. Then the tendons are retracted exposing the CFL, and the quality of the CFL is determined. A ligament that is simply stretched can be divided and imbricated (Fig. 13-3). The previously ruptured ATFL or CFL often is scarred down to capsule and tendon sheath and requires dissection to disclose their location and character. For the CFL, it is necessary to determine whether the remaining tissue can be used in the secondary repair. A distal avulsion from the calcaneus can be reattached with suture anchors. I prefer to use a bioabsorbable anchor to avoid problems from retained hardware in the event of future ankle problems that might call for a drill hole in this location. A proximal avulsion can be reattached with sutures through drill holes in the fibula (being careful to consider the anterior talofibular reconstruction) or with a suture anchor. The greatest difficulty arises with a midsubstance tear that has extensively scarred to the surrounding tissue. Careful dissection usually will define a ligamentous remnant that can be imbricated.

4 In the case of an ATFL avulsed from the fibula, and to be certain of sufficient tissue for the ATFL reconstruction, a periosteal flap that is continuous with the capsule and the anterior talofibular scar can be created.

5 Nonabsorbable or slowly absorbable sutures are placed in the ligament. A small bony trough is created above the anterior and inferior border of the distal end of the fibula, and several drill holes are made with a small drill bit or Kirschner wire (Fig. 13-4). This permits imbrication of the ends of the cut ligament and capsule, as well as the anchoring of the ligament into bone. In the few cases in which the ATFL has avulsed from the fibula, it also is feasible to reattach the ATFL with suture anchors. As mentioned under number 3 previously, it is preferable to use bioabsorbable anchors here to avoid the potential problem of extricating a metal anchor that is situated in the exact location where a bone tunnel must be placed for a tendon graft reconstruction should the anatomic reconstruction fail or be disrupted in a future injury.

6 The sutures are tied over a bony bridge on the lateral aspect of the fibula, with the ankle held in neutral dorsiflexion and slight eversion (Fig. 13-5). The surgeon must be careful to ensure that there is no anterior displacement force on the ankle while the sutures are being tied. To prevent this, a bump is placed under the distal leg to relieve any anterior directed force on the heel.

7 Sutures are placed in the CFL first, followed by the ATFL, and then the lateral capsule. The sutures are tagged or grouped to be tied only after all sutures are in place. Sutures are tied beginning with the CFL, then the ATFL, and concluding with the anterior capsule. The ankle is positioned in relaxed plantarflexion when the sutures in the CFL are secured and in slight dorsiflexion and eversion for tying the sutures in the ATFL.

8 After securing the repair, the stability is checked and further imbrication performed as needed.

9 Before closure, attention is directed to the inferior extensor retinaculum, which is imbricated or sutured to the periosteum over the fibula (Fig. 13-6). This provides additional stability to the subtalar area and protection to the ATFL and may add some proprioceptive feedback. I believe that it is an important addition to the Brostrom technique, as noted by Gould and others.^35,43–45

10 The subcutaneous tissues are reapproximated with absorbable sutures, and the skin is closed with a subcuticular technique.

11 A U-shaped splint and a posterior splint or a walking boot is applied.

Figure 13-1 Anterior lateral incision paralleling the border of the fibula used for anatomic repairs and reconstructions.

Courtesy Matthew Morrey, MD.

Figure 13-2 Stretched anterior lateral ligaments found in typical chronic ankle sprains.

Courtesy Matthew Morrey, MD.

Figure 13-3 Imbrication of stretched ligaments in anatomical reconstructive procedure.

Courtesy Matthew Morrey, MD.

Figure 13-4 Bony trough used for attachment of anterior talofibular and calcaneofibular ligaments to bone.

Courtesy Matthew Morrey, MD.

Figure 13-5 Sutures tied over bony bridge on anterior lateral fibula.

Courtesy Matthew Morrey, MD.

Figure 13-6 Imbrication of inferior extensor retinaculum to periosteum of distal fibula.

Courtesy Matthew Morrey, MD.

Postoperative care

For athletes, the patient is placed in a short-leg splint with the foot in neutral dorsiflexion and slight eversion. The splint remains in place until the first postoperative visit, which usually occurs between 6 and 10 days from the day of surgery. The patient is on crutches—nonweight bearing until this visit. At the first postoperative visit, the patient is placed in a walking boot or cast and begins weight bearing as tolerated. This is continued for 3 to 4 weeks until the next office visit. During this second phase, the patient may start dorsiflexion and eversion movement if in a boot, and at 4 weeks, the patient is placed in an ankle stirrup brace. Gentle active inversion is begun at 4 weeks in association with Achilles stretching. At the same time, proprioceptive training and resistive exercises with rubber tubing are begun. The patient is allowed to progress from stationary biking to pool running to outdoor walking and straight-line running. As long as the patient shows no pain or undue swelling, rehabilitation continues as tolerated with figure-eight running in progressively smaller loops, and ultimately, cutting drills are instituted. The athlete then is allowed to resume activities specific to his or her sport, with return to competition once each task of the sport can be accomplished. For 6 months following the repair, the patient is instructed to use a protective ankle brace and/or taping to protect the repair. The typical return to competitive sport participation is 12 weeks (range 10 to 16 weeks), although it may take closer to 6 months for swelling and discomfort to resolve fully.

For nonathletes, a 10- to 12-week period of protection is warranted, the first 4 to 6 weeks with the patient being in a cast or walking boot with limited exercise and the second 6 weeks with the patient being in a removable brace or walking boot when a more aggressive rehabilitation program is begun. Resumption of vigorous exercise or recreational sports generally takes longer in this population. Although I believe in individualizing the rehabilitation program to the patient and the pathology, a table is provided as a general guideline (Table 13-2).

Table 13-2 Rehabilitation Program for Surgically Reconstructed Lateral Ankle Ligaments

Failed Lateral Ankle Ligament Reconstruction

Of patients who undergo a lateral ankle reconstruction, 5% to 15% may proceed to failure, requiring further intervention. Perhaps the most common cause for failure is recurrent instability. The primary surgical procedure may have been inadequate, the patient may have reinjured the ankle, or there may have been inherent factors that predisposed a patient to failure (benign joint hypermobility syndrome, Marfan’s syndrome, or Ehlers-Danlos syndrome).⁴² The patient often describes a loose feeling in the ankle or the sensation of “giving way” or “turning easily.” Another cause of failure in lateral ankle reconstruction is chronic pain, constant or only during activity, resulting from intra-articular pathology or postoperative stiffness.

In addition to a thorough history, it is important to obtain a record of the primary procedure, if possible. Stress tests of the lateral ligaments should demonstrate laxity. Limited range of motion of the ankle and subtalar joints can be observed in patients who were overtightened at their original reconstructive procedure. The alignment of the hindfoot should be evaluated. Varus alignment of the heel will predispose a patient to failure of a lateral ligament reconstruction.

Radiographs of the foot and ankle should be obtained to evaluate the presence of bony pathology. Stress radiographs or fluoroscopy can aid in the diagnosis of recurrent instability or an excessively tight reconstruction. Intra-articular pathology, such as osteochondral lesions, can be diagnosed with magnetic resonance imaging (MRI). Computed tomography (CT) scans are helpful in defining previous bone tunnels. Nonoperative measures may be effective in the management of recurrent instability; however, these patients typically require a second attempt at surgical stabilization.

Treatment

Reconstructing the lateral ligament with a free tendon transfer using the semitendinosus or the gracilis tendon is recommended, performed in a manner similar to the method used when harvesting for an anterior cruciate ligament autologous graft. After the graft has been harvested, it is prepared by sizing it for diameter and length. Generally, the doubled semitendinosus is 9 to 11 cm in length and approximately 5 to 6 mm in diameter, whereas the gracilis is somewhat smaller. It also is possible to use an allograft tendon, and a larger tendon such as the anterior tibial tendon can be cut to the appropriate diameter for drill holes.

The lateral ankle is exposed through one of two incisions chosen on the basis of the underlying pathology. When the pathology is limited to the previously reconstructed lateral ligamentous complex, a small, curvilinear incision paralleling the anterior and distal border of the fibula is used, similar to the incision for the previously described Brostrom procedure (see Fig. 13-1). For cases with more extensive pathology (peroneal tendon tears or anterior osteophytes), a longitudinal incision is made over the posterior border of the fibula, curving distally to the sinus tarsi and the anterior process of the calcaneus. With both approaches, the ankle joint is exposed and the anterolateral capsule is divided, preserving as much potentially useful tissue as possible.

For proper graft placement, the insertion sites of the ATFL (talus and distal fibula) and CFL (distal fibula and calcaneus) are exposed. The surgeon then drills a 4.5- to 6.0-mm tunnel in the talus, depending on the size of the graft and the size of the interference fit screw being used. Bioabsorbable screws currently vary in size from 4 to 11 mm. I have found that the 5- to 5.5-mm screw works best in the ankle. The tendon graft is captured with a suture loop using the Arthrex Biotenodesis System and inserted into the bone tunnel to a depth of approximately 20 mm before the bioabsorbable screw is tightened against the tendon within the bone tunnel. Another option is to drill a tunnel in the talus to a depth of 25 to 30 mm and use a Beath pin to pass the sutures from the end of the tendon graft through the tunnel in the talus and out the medial side of the foot. With tension applied to the tendon through the sutures, an interference screw can be placed next to the tendon to secure the graft in the talus. Once the graft is secure in the talus, a tunnel is drilled from the anterior distal fibula at the origin of the ATFL through the distal fibula and into the area of the proximal peroneal groove. When the procedure is performed through a Brostrom-type incision, a separate 2-cm incision is made for insertion of a retractor to protect the peroneal tendons. A second fibular bone tunnel is drilled at the origin of the CFL and passed posterior to exit at the posterior fibula at the same exit site as the previously drilled fibular tunnel. Now a V-shaped channel in the distal fibula exists. A suture passer is placed through the posterior fibular tunnel, exiting anterior, and the sutures in the tendon graft are passed into the fibula, creating an ATFL graft. The suture passer next is passed posterior through the distal fibular tunnel, and the sutures in the tendon graft are passed out the distal fibula to create a CFL graft. It is important to keep a clamp around the graft at the posterior fibula to allow tensioning of the separate limbs of the graft. A tunnel is drilled in the lateral calcaneus at the site of insertion of the CFL for the tendon graft, with the depth of the tunnel being sufficient enough to pull the entire tendon graft length into the bone tunnel. A Beath pin or Keith needle then is used to pass the tendon graft sutures through the plantar medial heel.

While holding the ankle in neutral dorsiflexion and neutral inversion/eversion, the surgeon applies tension to the graft. A bioabsorbable screw is placed with an interference fit in the calcaneal bone tunnel to secure the graft (Fig. 13-7). Alternatively, the Arthrex Biotenodesis System can be used to insert the tendon in the bone tunnel and fixate the graft with the bioabsorbable screw. Once the graft is secured and the tension is judged to be adequate, the ankle is tested for stability and range of motion, and stress radiographs are performed under fluoroscopy. If the ankle is still unstable, the screw in the calcaneus is removed, the graft further tensioned, and the screw replaced with the heel in slight eversion. The graft is secured to the periosteum of the fibula at the entrance and exit holes with absorbable suture. The inferior extensor retinaculum or other local tissue can be used for augmentation if further stability is required.

Figure 13-7 Bioabsorbable screws placed with an interference fit in the talar and calcaneal bone tunnels to secure the tendon graft.

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