Lateral Ankle Instability
Andrew J. Rosenbaum
Sterile Instruments/Equipment
Tourniquet
Sharp Senn retractors
Freer elevator
Wire driver/drill
Littler dissection scissors
Small joint arthroscope and ankle distractor (if arthroscopy is to be performed at the time of surgery)
Implants
FiberTak suture anchors (Arthrex, Naples, Florida, USA)
InternalBrace (Arthrex, Naples, Florida, USA)
Positioning
Supine on operating room table
Bump placed under ipsilateral hip to ensure foot is straight up and down
Thigh-knee holder and noninvasive ankle distractor applied next if arthroscopy to be performed
Use a gel pad to minimize pressure on peroneal nerve and the popliteal space.
Surgical Approach
Anterior approach begins 1.5 cm proximal to the tip of the fibula and extends 1.5 cm distal distally in line with the fifth metatarsal base (Figure 17-1).
Avoid superficial peroneal and sural nerve branches.
Identify the interior extensor retinaculum and tag it with a no. 0 absorbable suture.
Identify the anterolateral capsule and release in a subperiosteal manner off the distal fibula.
Do not stray too far anterior to prevent iatrogenic injury to the superficial peroneal nerve.
The posterior landmark is the peroneal sheath, which allows inspection of the tendons.
Address any peroneal tendon pathology at the time.
If additional tissue is needed for repair, elevate the distal fibula periosteum from distal to proximal.
Ligament Stabilization
Excise any loose ossicle while taking care to preserve the capsule and integrity of the anterior talofibular ligament (ATFL).
Prepare distal fibula for healing following ligament fixation with a rasp and bone rongeurs.
Calcaneofibular ligament is not routinely incorporated into the repair, because outcomes are not improved when done in conjunction with ATFL repair.1
Figure 17-1. Incision used to address lateral ankle instability. A larger incision is used, or this incision is extended, if peroneal tendon pathology necessitating treatment is present. Courtesy of Andrew Rosenbaum, MD.
The InternalBrace is then placed at the ATFL footprint on the talus.
Identify the nonarticulating surface of the lateral border of the talus.
Use a 3.5-mm drill in a direction of 45° medial and parallel to the floor, with the foot in neutral to avoid entering the sinus tarsi or ankle joint.Related posts:
Management of Metatarsalgia and Equinus Contracture: Gastrocnemius Recession, Percutaneous Tendoachilles Lengthening, and Diaphyseal Metatarsal Shortening Osteotomy
Management of Lesser Toe Deformity: PIP Arthroplasty and Extensor Lengthening
Correction of the Rigid Flatfoot
Peroneal Tendinopathy
Fifth Metatarsal Stress Fractures
Arthroscopic Management of Osteochondral Lesions of the Talus
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