Surgical Treatment of Ligamentous Injuries About the Ankle

Lisa Wasserman MD, FRCS(C)

Annunziato Amendola MD, FRCS(C)

History of the Technique

Ligamentous injury and surgical repair about the foot and ankle may involve the lateral ligament complex, the syndesmosis ligaments, or the ligaments of the medial side of the ankle joint. This chapter details the indications and surgical technique of anatomic and nonanatomic lateral-sided reconstructions, treatment of syndesmosis injuries, and the management of the emerging entity of medial ankle instability.

There have been several modifications of the original procedure, described by Brostrom¹ in 1966, of direct repair of the lateral ankle ligaments. Gould et al.² recommended proximal advancement of the inferior extensor retinaculum to the distal fibula to reinforce the repair and to stabilize the subtalar component of recurrent instability. This modification has been shown to be biomechanically stronger in reducing anterior drawer and talar tilt when compared with the Watson-Jones and Chrisman-Snook procedures in a cadaver model.³ Karlsson et al.⁴ advocated shortening of the elongated lateral ligament complex and reattachment to the fibula through drill holes. More recently, suture anchors have become the preferred mode of reattachment of the ligaments.⁵

Nonanatomic reconstructions (Evans, Watson-Jones) have generated concern regarding excessive tightening of the subtalar joint and the sacrifice of the peroneus brevis, a dynamic stabilizer of the ankle.⁶^,⁷ These issues have contributed to the decrease in popularity of nonanatomic repairs as first-line procedures for lateral ligament instability. However, they remain useful in the setting of revision reconstructions for lateral instability.

Indications and Contraindications

Complaints of instability must be probed to determine whether true mechanical instability due to ligamentous laxity exists. This is differentiated from functional instability related to muscular weakness or pain inhibition reflexes from associated injury. If pain is not present between sprains, true mechanical instability may be the primary problem. Stress radiographs have repeatedly demonstrated low specificity due to the large variability in physiologic values and the lack of correlation with clinical symptoms and therefore may not be useful on a routine basis.⁸ Initial treatment for all patients, regardless of the duration of the instability, involves a therapy program of peroneal muscle strengthening and proprioceptive training, combined with use of a lace-up brace for high-risk activities. This regimen is effective in the majority of patients. The remaining patients are candidates for operative stabilization, provided that they exhibit true symptoms of mechanical instability and have ligamentous laxity on physical examination.

Surgical Techniques

Anatomy

The lateral ligamentous complex of the ankle joint consists of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). A fourth structure, the lateral talocalcaneal ligament (LTCL), is variable and may be found coalescing with the
ATFL and/or the CFL. The ATFL is the primary restraint to inversion in plantar flexion. It also resists anterolateral translation of the talus in the mortise. It originates 10 mm proximal to the tip of the fibula, just lateral to the margin of the articular cartilage. It is directed 45 degrees medially toward the talus in the coronal plane and inserts directly distal to the articular cartilage of the talar body, averaging 18 mm dorsal to the subtalar joint.⁹ It is the weakest of the lateral ligaments.

The CFL is the primary restraint to inversion when the ankle is in the neutral or dorsiflexed position. The CFL originates on the anterior edge of the fibula, 9 mm proximal to the distal tip. It subtends an angle of 133 degrees from the posterior border of the fibula, inserting on the calcaneus 13 mm distal to the subtalar joint, deep to the peroneal tendon sheaths.⁹ The PTFL is the strongest of the collateral ligaments and bridges the posterolateral tubercle of the talus to the posterior aspect of the lateral malleolus.

Gould Modification of Brostrom Technique

The skin incision begins at the tip of the distal fibula and is carried proximally in an inverted “J” along the anterior border of the fibula over a distance of 4 cm. Care is taken to avoid the intermediate dorsal cutaneous branch of the superficial peroneal nerve. The inferior extensor retinaculum is dissected free at its proximal border for later use (Fig. 63-1). The peroneal sheath is opened distally to allow retraction of the peroneal tendons. The CFL is identified under the tendons and the ATFL is identified within the capsule more anteriorly (Fig. 63-2). The ligaments and capsule are then sharply incised 2 mm distal to the fibula, and a periosteal flap is raised proximally off the bone. A burr is used to roughen the fibula anteriorly and distally. Three suture anchor drill holes are then placed, two at the anterior border of the fibula, 1 cm from the tip, and the third slightly more distally (Fig. 63-3). The suture anchors are inserted. Alternatively, transfibular drill holes may be used instead of suture anchors. These are made with a 2.0-mm drill bit and small, sharp, bone-holding forceps are passed through the drill holes to complete the tunnels. This is technically more difficult and time-consuming and risks breakage through the tunnel sites. Next, redundancy of the capsuloligamentous complex is excised and the ligaments are reefed, beginning posteriorly with the CFL. The sutures are tied with the foot held in dorsiflexion and eversion, and this position is maintained throughout the remainder of the case. The periosteal flap of the distal fibula is then sutured down over the newly reattached ligaments. Finally, the inferior extensor retinaculum is mobilized proximally (Fig. 63-4) and secured over the repaired ligaments with absorbable suture (Fig. 63-5). The skin is closed with an absorbable monofilament subcuticular stitch followed by surgical tapes. A non–weight-bearing fiberglass cast is applied with the foot maintained in its dorsiflexed and everted position.

Fig. 63-1. The inferior extensor retinaculum (held in forceps) is mobilized for use later in the repair.

Fig. 63-2. The ATFL is exposed (arrow) and the metal probe identifies the distal tip of the fibula.

Nonanatomic Reconstruction

Colville et al.⁷ developed a reconstruction using a split peroneus brevis tendon graft that reproduces the orientation of the native ATFL and CFL. The advantage of this configuration
is that subtalar laxity will be limited only to the physiologic amount allowed by the intact CFL. This technique may be modified by using an Achilles tendon bone-block allograft in place of sacrificing the peroneus brevis tendon.

Only gold members can continue reading. Log In or Register to continue