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Lateral ankle ligament reconstruction

    Overview

    Learn the Lateral ankle ligament reconstruction surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Lateral ankle ligament reconstruction surgical procedure.
    One should be clear of the difference between functional ankle instability, the joint feeling and behaving unstably though with competent mechanical restraints, and mechanical instability where these no longer fulfil their purpose. The former is far more common but the initial management of the post-traumatic unstable ankle is most commonly conservative, irrespective whether functional or mechanical. A successful outcome van be expected in most cases.
    It should also be appreciated that some cases with demonstrable lateral ligamentous laxity during examination will be dynamically stable during function having undergone an appropriate course of muscle strengthening and proprioceptive rehabilitation. The indication for a ligament reconstruction is symptoms and a functional problem, and not an examination finding. Such patients rarely require operative management.
    If rehabilitation and conservative management fail to stabilise the ankle then the main complaint referable to the ligaments will be one of instability and not pain. Patients with ankle pain as a prominent feature will probably also require an ankle arthroscopy to treat an intra-articular source of pain. It is important in such patients to be clear about the location of the pain. The ankle joint itself is only one possibility as pain can also come also from injury to the postero-medial structures and tendons or postero-lateral tendons after an ankle sprain and this may require additional management.
    Patients with atraumatic onset lateral ligament instability are a separate subgroup, who may suffer either with more generalised ligament insufficiency or more rarely neurological issues and require different operative management of their instability than described in this technique.
    Readers will also find the description of the Zimmer-Biomet Juggerknot used in a Brostrum ligament reconstruction useful to read at https://www.orthoracle.com/library/brostrom-lateral-ligament-reconstruction-using-juggerknot-suture-anchorzimmer-biomet/

    Indications

    INDICATIONS.
    –Primary reconstruction for symptomatic lateral ankle instability which has failed conservative management
    –Revision reconstruction in patients with good quality local (and general) soft tissues
    SYMPTOMS & EXAMINATION.
    Not all patients with lax lateral ligaments will be symptomatically unstable. Overall ankle stability is conferred by a combination of active muscle function and the static ligamentous stabilisers. If the muscle tone , power and co-ordination is good then despite lax ligaments on examination a patient may have no mechanical problem and therefore not require reconstruction.
    Patients appropriate for this type of ligament reconstruction will have a history on an initially stable ankle which has deteriorated after one or many episodes of trauma. The instability may be to the extent that the patient has significant re-injuries or simply more minor episodes during which the ankle feels unstable. If severely unstable these symptoms may be during the activities of daily living or may be just during more vigorous or sporting activity.
    Pain is normal after episodes of overt instability for a period of time. If pain occurs unrelated to these episodes (which is not uncommon) it usually indicates the presence of intercurrent pathology within the joint ,resulting also from trauma. Most often this is synovitis , arthrofibrosis or chondral/osteochondral pathology. This will require specific treatment during any surgery as any intra-articular pathology can also contribute to feelings of instability from the joint. The location of pain is also important to be clear on. In most cases it will be antero-lateral ankle , but specifically enquire about both true lateral/posterolateral pain as well as postero-medial pain. The former may indicate peroneal tendon pathology which may require injection for synovitis or repair of tears. In all cases of instability look for peroneal tendon subluxation as this will have similar symptoms and should be treated with a different operation. Occasionally it may be secondary to posterior ankle impingement. Postero-medial pain should certainly make one suspicious of posterior impingement which may require treatment or Tibilais posterior involvement. Anterior and posterior impingement provocation tests should also be performed. The mechanism of injury with a “sprain” is that the ankle is forced not only only into inversion but also plantar-flexion which is how posterior compression occurs which can result in posterior impingement developing.
    On examination there may be ankle level swelling but this is not consistent. The tendons should be specifically examined for problems as noted above. The Anterior Talo-Fibular ligament restricts the ankles anterior translation in plantar-flexion (tested by the anterior drawer test) and stabilise the ankle in plantar flexion and inversion. The Calcaneo-Fibular ligament resists inversion with the ankle in dorsiflexion (tested by the Talar tilt test). Both should be examined though may appear stable if the patient has good resting muscle tone or there is pain during examination.
    INVESTIGATIONS.
    MRI: All patients require an MRI scan. This can be after conservative management of instability fails. If performed early or immediately after injury pathologies that will usually settle (such as bone oedema) will also be detected. The information yielded by MRI about the lateral ligaments will denote only that they have been injured (a fact normally gleaned from a well taken history) and gives no idea on the stability of the injured ligaments (irrespective of the MRI grading of injury). It is key to assessment of the injury never the less. An intercurrent osteochondral injury will need treatment and the posterior ankle and peroneal tendons should also be viewed.
    On occasion rarer injuries may result from the weight-bearing and inversion (such as a lateral process fracture of the Talus) and are easiest spotted on MRI.
    ULTRASOUND: Some patients require ultrasound.Intercurrent tendon pathology is sometimes better diagnosed with ultrasound and impingements can be treated under ultrasound guidance in advance of operation which may limit operative intervention simply to the ligament reconstruction (see section on posterior ankle decompression).
    X-Ray: Image Intensifier screening is used on-table at the start of the operation to screen the ankle for cases which are symptomatically unstable but in whom ligament examination is normal or equivocal when the patient is awake. It is possible that the ankle ligaments may be mechanically stable but the joint functionally unstable (one cause of which is intra-articular pathology). These can also be performed with the patient awake of course.
    NON-SURGICAL ALTERNATIVES.
    –Physiotherapy: The first line of management for most cases should be a course of frequent and well supervised rehabilitation , concentrating on active proprioception and strengthening.
    –Braces: There are a variety of devices with subtle individual advantages . They are an inconvenience for day to day usage and most often just worn for ” at risk” sporting activities
    -Taping: A variety of taping materials and taping patterns around the ankle exist. These act by a combination of improving the proprioceptive feedback by cutaneous stimulation and providing a mechanical restraint.
    SURGICAL ALTERNATIVES.
    Allograft. Wright medical graft jacket for example.
    Autograft. Hamstring free tendon graft can be used.
    Neo-ligament. Various braided tapes are available, such as the Arthrex Internal brace or the Zimmer-Biomet JuggerKnot, detailed on Orthoracle at https://www.orthoracle.com/library/brostrom-lateral-ligament-reconstruction-using-juggerknot-suture-anchorzimmer-biomet/
    Evans procedure:Non-anatomical ligament reconstruction, routing Peroneus Brevis direct through a Fibula bone tunnel.
    Chrismann-Snook: Anatomical ligament reconstruction remaking the ATF and CF Ligaments with Peroneus Brevis
    CONTRAINDICATIONS.
    -Congenitally lax soft tissues: In patients with a high Beighton score (who usually with multiple instabilities of other joints ) a tendon transfer procedure or other form of graft will be required to stabilise the joint.
    -Revision cases: In cases where insufficient quality tissue is present beneath the fat layer of the ankle
    –Heavy demand, Heavy athletes: This is very relative and subjective as a contra-indication.
    Instability of neurological origin: for example an unstable cavo-varus, which will be more appropriately stabilised with a triple fusion or double fusion.

    Setup

    GA or regional anaesthetic
    Popliteal block & local infiltration adequate for post-op pain relief
    Patient supine or slight lateral tilt
    (consider set up initially for ankle arthroscopy )
    Rolled-up sterile towels behind the operated calf to ease access to postero-lateral aspect of ankle
    Thigh tourniquet & Flowtron applied to non-operated calf.
    Peri-operative antibiotics and LMW Heparin , to continue 2-4 weeks whilst in cast.

    Operation

    The skin incision runs from the region of the antero-lateral arthroscopic portal(1) to posterior to the fibula(2), ending over-lying the peroneal tendons (3).
    It is useful when choosing exactly where to place this skin incision to stress the hindfoot into varus whilst palpating the tip of the fibula and lateral talus. This will give a good appreciation of where the lateral ankle as well as subtalar articulations are. This surgical approach should take one down onto the lateral talus, though it is easy to wander a bit inferior and end up too low in the subtalar joint unless this step is performed to allow one to place the incision over the ankle and not the subtalar joint.
    An initial ankle arthroscopy is performed and the portals closed.
    A determination will have been made before the arthroscopy (and sterile preparation of the leg) of the stability of the Anterior Talo-Fibular and Calcaneo-Fibular ligaments, comparing to the opposite side as required.
    If examination is equivocal then the ligament stress testing can be performed under Image Intensification .
    An alternate longitudinal incision is helpful if intercurrent surgery to the Peroneal tendons is required. This incision runs along the distal Fibula to its tip and then goes in an anterior/superior direction towards the 3/4th metatarsals. This gives much better exposure of the peroneals and good enough exposure for the ligament reconstruction.

    Once in the fat layer the object is to define the deep fascial layer, used to reconstruct the lateral ligaments, the initial steps being to seek and avoid superficial peroneal and sural nerves.
    In dissecting through the fat layer the structures to be avoided are the superficial peroneal(1) and possibly sural (2) nerves.
    Once these have been found the fat can be blunt dissected off the fascia using dry swabs. The superficial Peroneal nerve is often found running in the line of the 4th toe and Metatarsal and it can on occasion be identified pre-operatively (then marked) by plantar-flexing the 4th toe.
    It is unlikely that the sural nerve will be in the operative field unless the skin incision has extended much behind the Peroneal tendons.

    The superficial peroneal nerve has here been identified (1). The sural usually sits posterior to the peroneal tendons at this level and so will rarely be seen unless the exposure extends too posteriorly.
    Both nerves are not always identifiable within the limits of the exposure.
    If either nerve is not demonstrably within the operative field it does not need to be sought.

    The superficial peroneal nerve (1) will run close to the antero-lateral portal. The sural nerve (2) runs behind the fibula(3), usually posterior to the peroneal tendons at the level of the ankle.This is quite a long skin incision and not required unless the distal peroneal tendons require intervention (as this case required).
    (This image shows the capsule already sharp dissected open which happens in a subsequent stage of the operation).

    The superior(1) and inferior(2) skin & fat flaps being scissors and blunt dissected off the underlying capsule. In the lower part of the wound the peroneal sheath can be also seen.
    The superior skin flap needs to have the fatty layer attached to it extensively undermined proximally. This should be up to 4-5 cm proximal to the Fibula tip, and can also be done with a swab.
    This dissection is aided by elevation of this flap with a Langenbeck retractor held by an assistant. The purpose of having the skin & fat elevated “as one” off the deep fascia is two-fold. Firstly it allows easy visualisation for proximal placement of the mattress sutures that will be used in the reconstruction. Secondly it provides a sufficient padding over the deeply placed suture knots which otherwise can be slightly bulky and produce local discomfort .

    In the inferior portion of the wound once the fat layer has been dissected off the deep fascia the Extensor digitorum muscle belly(1) can be seen.
    This whole layer of deep fascia is defined as one continuous layer and used for the reconstruction, being under-sewn beneath the superior layer.


    The deep fascia is divided in the same line as the skin incision, exposing the lateral aspect of the ankle joint.The ATFL is rarely identifiable as a discreet structure following injury. One simply encounters a broad sheet of amorphous but tough fascial tissue. The joint should be inspected , and in particular the deep aspect of the capsule , as bony avulsions in this area are not unusual. These are a potential source of ongoing pain if incorporated into the ligament reconstruction and so should be removed.
    The Peroneal tendons once exposed (1) define the inferior limit of the dissection. Their sheath is in this location fairly inconsequential and is best dissected open carefully to avoid injuring the underlying tendons. Significant pathology such as tears will present with discreet symptoms in the line of the tendons, so will have been identified pre-operatively. There is no need for a widespread exposure of the tendons, unless surgery to them is planned.

    The inferior extent of the dissection is defined by exposing the peroneal sheath, which then needs to be opened to identify the Calcaneofibular ligament deeply placed beneath the tendons.The peroneal tendons retracted posteriorly(1) with a Langenbecks retractor to expose the deep surface of their sheath. This is where the Calcaneo-fibular ligament(CFL) is usually easily identifiable as a discreet structure(2), whether injured or not. Brostrum reported in his landmark 1965 paper that the CFL had been detectably injured in 60% of cases undergoing a lateral ligament reconstruction.
    The fat should be dissected with the overlying skin off the deep fascia certainly 5cm at least above the level of the Fibula tip .This allows both clear identification of the layer to be reconstructed but also a good layer of fat “padding” to sit on top of the non-absorbable suture knots following reconstruction.

    The first locked suture is placed through a cuff, anteriorly placed, of the inferior capsular flap(1), avoiding the superficial peroneal nerve. A non-absorbable suture(eg 2 FibreWire Suture) is placed from “outside to in” to leave the knot extra-articular. Only a relatively small cuff of this inferior layer should be taken with this and every subsequent suture.It is very helpful to have an assistant place a Langenbeck retractor beneath the fat & nerve in this superior edge of the exposure to aid correct placement of this first suture in the deep fascia.
    Sometimes this fascial layer may be of lesser quality and the locked suture cuts out. If this occurs rather than taking a single “bite” of tissue before tying the suture take two bites and use a slightly different entry point for the second one, broadening how much tissue is taken. The suture will then not cut out.

    Having locked the first 2 Fibre-wire suture into a thick but narrow part of the inferior deep fascia(with the knot externally placed, 1) the suture is taken superiorly and a much wider flap of the deep fascia(2) is then under-sewn.This step is aided by having an assistant place a Langenbeck retractor (not shown) into the superior flap , specifically beneath the fat layer, so that just the deep fascia is seen and a clear and adequate exit point for this key suture is achieved.
    The free end on the Fibre-wire suture (3) will next also need to be sewn similarly into the superior flap and at an adjacent point. It will need to be mounted on a free (Mayo-type) needle.
    The peroneal tendons (4) and seen in the inferior aspect of the wound.

    A Mayo needle (1) is mounted onto the non-needle end of the 2 Fibrewire suture which is then sewn back up next to the first suture in the superior flap at point 2.

    The much smaller inferior flap is ready to be pulled under the much bigger superior flap, once the first mattress suture is placed

    Once both ends of the Fibrewire suture(1)have been placed they can be tightened to confirm that the lower flap pulls up well beneath the superior flap(2). This should not be tied off at this stage.
    The correct technique involves placing all mattress sutures initially before tightening them, during which the foot is held in dorsi-flexion and eversion.
    Most ankles will have room for 4 or 5 such sutures.
    If the Calcaneo-Fibular ligament also requires reconstruction the orientation of this most in ferior suture should be slightly different. A similar mattress type stitch is used but it is placed in an intra-ligamentous position and oblique orientation with respect to the other sutures. It is important that the peroneal tendons are not caught by this suture posteriorly.

    Approximately 4-5 2 Fibrewire mattress sutures are placed in this way.

    The Fibrewire sutures are sequentially tied from anterior to posterior with the foot supported in a position of slight dorsiflexion and eversion.Care is taken to ensure that the cutaneous nerves are not caught in the closure.
    The fat is closed with 2.0 Vicryl and skin with 3.0 Vicryl subcutaneously.

    Once the repair is completed it is now tested and if any laxity still exists then a further over-sew of the suture line using a continuous 1 Vicryl suture will rectify this. Skin closure is with 2.0 & 3.0 Vicryl sutures.
    The patient is then placed into a below knee backslab with the ankle in neutral.

    Post Operative

    4 weeks in short post-operative cast, non-weight bearing
    The first 2 weeks of this in back-slab
    Dressing change at 2 weeks.
    By 4 weeks into a medio-lateral stabilised ankle brace and commence full weight bear as soon as able.
    Physio to commence, working on in-line ankle range and strength , progressing to balance and proprioceptive rehabilitation, including peroneal strengthening.
    My own recommendation is that no specific mobilisations ( active or passive) are used on the subtalar joint. Circumducting the ankle does risk over-stressing the repair at an early stage. Adequate Subtalar movement will be regained during functional rehabilitation phase.
    A static bike from 5 weeks, Cross-training from 7-8weeks and light -jogging likely to commence sometime after 10 weeks.
    Initial return to sport is likely to require an appropriate brace for the first month.

    Recommended Reading

    The modified Brostrom procedure for lateral ankle instability
    Foot & Ankle 1993 .14:1-7
    W G Hamilton F M Thompson S W Snow
    In a cohort of half professional dancers and half other a “double-breasting” soft tissue procedure was performed , including a discreet advancement of the fascia over Extensor digitorum Brevis (Gould modification).
    28 reconstructions with no failures and 26 excellent results , 1 good and 1 fair followed up at a mean of 64 months.
    The indications were either symptomatic dysfunction despite rehabilitation or a grade 3 laxity (in other words some patients may have been mechanically stable).
    Clinical outcome after anatomical reconstruction of the lateral ankle ligaments using the Duquennoy technique in chronic lateral instability of the ankle
    J Bone Joint Surg 90-B.2008. 50-56.
    S P Muijs , P D S Dijkstra, C F A Bos
    An advancement/tightening procedure for the ATF and CF ligaments without division of the ligaments.
    A clinical follow up at a mean of 13 years. 48% excellent results , good in 33% and fair in 19%. Both Talar tilt and anterior drawer test remained improved significantly in all and were not statistically different from the contralateral side.
    Surgical versus functional treatment for acute ruptures of the lateral ligament complex of the ankle in young men
    J Bone Joint Surg 2010.92. 2367-74.
    H Pihlajamaki et al
    Acute grade 3 lateral ligament ruptures (confirmed on stress X-Rays) in young Finnish men were treated either with ligament repair ( 15 persons available for long term review) or functional rehabilitation and ankle brace(18 persons available for long term review). They were followed up at a mean of 14 years. All returned to previous activity levels and there was no difference noted upon stress testing the ligaments. Re-injury level however was significantly higher in the conservatively treated group.
    The aetiology and prevention of functional instability of the foot
    Journal Bone Joint Surg (Br)1965 47:678-685
    Freeman
    Only 40% of lax ankles are symptomatically unstable


    Reference

    • orthoracle.com

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