Research Article

Research Article

Minimally invasive reconstruction of the lateral ankle ligament using tendon allografts to treat chronic ankle lateral instability

Wenge Ding, Wenliang Li, Kejie Wang*

Department of Orthopaedic Surgey, The Third Affiliated Hospital of Soochow UniversityChangzhou, China

*Correspondence author: Kejie Wang, Department of Orthopaedic Surgery, The Third Affiliated Hospital of Soochow University185 Juqian Road, Changzhou 213001, China. Telephone number: 8651968871311. Fax number: 865198870000. E-mail: sineboat@126.com.

Citation: Weng Ding, Zhiwei Liu, Kejie Wang. Minimally invasive reconstruction of the lateral ankle ligament using tendon allografts to treat chronic ankle lateral instability. J Minim Invas Orthop, 2015, 2(5), e12. doi: 10.15383/jmio.12.

Competing interests: The authors have declared that no competing interests exist.

Conflict of interest: None

Copyright: 2015 By the Editorial Department of Journal of Minimally Invasive Orthopedics. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract:

Background: Ankle sprain is the most common injury and further improvement in understanding of this injury is still needed. Methods: From August 2010 to July 2013, 23 patients with chronic post-injury ankle instability underwent minimally invasive surgical ligament reconstruction. All of the 23 patients underwent follow-up with the median follow-up of 12 months (range, 8 to 26 months). Surgical outcomes were evaluated during follow up. Results: Eighteen patients were post-operatively scored as excellent, 3 as fair, and 2 as pass; therefore, the excellent/fair rate was 91.3%. The mean pre-operative American Orthopedic Foot and Ankle Society Ankle Hindfoot (AOFAS) score was 70 (range, 65–75). The mean post-operative score was 95 (range, 90–98). Conclusion: Minimally invasive reconstruction of the lateral ankle ligament using tendon allografts could be suitable for patients with chronic ankle instability due to lateral ankle ligament injury.

Keywords: Ankle, Ankle sprain, Ankle lateral instability, Ligament reconstruction

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Introduction

Ankle sprain is one of the most common injuries occurring in physically active populations. It is estimated that 23,000 ankle sprains occur in the United States daily, which means one out of every 1000 people will sprain their ankle each day[1]. Although ankle sprains are considered minor injuries, they represent a significant public health problem. It is estimated that each year up to 1.6 million

 

patients with sprained ankles seek medical treatment and more than 8,000 are hospitalized. The main risk factor for ankle sprain is a history of previous sprain injuries. Approximately 30% of first-time patients eventually develop chronic ankle instability, and this could even be as high as 70% [2]. Patients who suffer from severe and recurrent ankle instability have reduced ankle function and quality of



Figure 1. Preoperative radiography of right ankle. a) AP radiography of right ankle before surgery. b) LP radiography of right ankle before surgery. c) Lateral stress test radiography of right ankle before surgery. d) Drawer test radiography of right ankle before surgery.

 


life. Although there have been numerous basic and clinical studies of ankle sprain injuries[3-5], further improvement in our understanding of these injuries is still needed. In order to understand the chronic ankle instability better, to summarize the operation experience and improve the understanding of this disease, we performed the retrospective investigation.

 

Data and methods

Clinical data

During the August 2010 to July 2013, 23 patients with chronic post-injury ankle lateral instability underwent surgical ligament reconstruction. Routine examination (Rheumatic diseases inspection items, ESR and C reactive protein etc.) prior to surgery ruled out rheumatic disease and confirmed that the ankle pain was primarily due to ankle lateral instability.

All patients had previously failed a 6-month program of repetitive conservative therapy. Fifteen of the patients were male and eight were female. Their average age was 40.2 (range, 28–65) years. All displayed instability while walking or ankle joint stuck. The anterolateral borders of their fibular apices were examined, and all had pain and tenderness of the tarsal sinus, which was aggravated by walking or dorsiflexion. Seven patients had additional medial ankle tenderness. All patients had ankle lateral instability with a positive drawer test. Radiograph (Fig.1a,b) showed 5 patients with a cystic lesion in the medial talus close to the tibiotalar joint; their stress radiographs were positive (Fig.1c,d). MRI images of the lateral aspect of the anterior talofibular and calcaneofibular ligaments were noisy in all patients, with 3 of them showing cystic lesions, local cartilage defects and subchondral sclerosis of the medial talus near the tibiotalar joint. Other causes of hind foot pain were ruled out. All of the patients initially underwent nonsurgical therapy, including oral administration of non-steroidal anti-inflammatory drug (NSAIDs), nerve blocks, physical therapy, and joint function training, for more than 6 months; however, the outcomes were unsatisfactory.

Treatment protocols

Surgical procedure

Location diagrams of the talar border, calcaneus, and lateral malleolus were prepared based on the palpable bony landmarks prior to the surgery (Fig. 2a) so that the anatomical site for ligament reconstruction could be quickly located during the surgery procedure.


Figure 2. Operation process. a) Photography of the right ankle during Preparation based on the palpable bony landmarks before surgery. b) Photography of the right ankle during 2 crossed K-wires were inserted through the skin along the fibular border. c) Radiography of the right ankle was used to confirm the positions of the guided needles. d) Photography of the right ankle during Allograft tendon was introduced through bone tunnel using Ethibond suture.


 

Patients received continuous epidural anesthesia while lying in a supine position with the hip on the affected side raised using sandbags to help with surgical positioning. Sterile covers were routinely placed and 2 crossed K-wires were then inserted through the skin along the fibular border (Fig. 2b) in the direction of the anterior talofibular ligament and the calcaneofibular ligament, which were outlined in the prepared anatomical diagram prior to the surgery, in such a way that the wires touched each other. Next, a hollow reamer (model 4.5) was used to expand the cavity to form an approximately arc-shaped open bone tunnel through which the prepared allograft tendon was introduced using Ethibond suture (Fig. 2d). Based on the pre- and intra-operative positioning of the anterior talofibular ligament and posterior talar tubercle (1 cm above the tarsal sinus) a guided needle was inserted through the skin and used to elongate the bone tunnel as much as possible. A second needle was inserted through the skin at

 

the site where the calcaneofibular ligament attached to the calcaneus (the angle between the ligament and the longitudinal axis of the fibula was 15 degrees). Both needles were approximately perpendicular to the lateral side of the foot. A small incision was made and then further enlarged using vessel forceps to avoid damage to the surrounding nerves and blood vessels. A C-arm fluoroscopy machine was used to confirm the positions of the guided needles (Fig 2c). A hollow reamer (model 6.0) was used to expand the cavity and the ligament allografts were subcutaneously pulled into the incision sites by the guided needles from the lateral side of the fibula (Fig. 3a). Extrusion screws were used to first fix the anterior talofibular ligament (Fig. 3b) and then the calcaneofibular ligament-bone attachment sites (Fig 3c). Joint stability was tested using the drawer test. Once the joint was stabilized, the incisions were sutured in multiple layers (Fig. 3d), followed by application of a sterile dressing and pressure bandage.


 


Figure 3. Operation process. a) Photography of the right ankle during ligament allografts were subcutaneously pulled into the incision sites by the guided needle. b) Photography of the right ankle during fixation of the calcaneofibular ligament with Extrusion screws. c) Photography of the right ankle during fixation the anterior talofibular ligament with Extrusion screws. d) Photography of Incisions after surgery of the right ankle.


 


Post-surgical care

All patients underwent the following post-surgical rehabilitation protocol:

Day 1: Avoid ankle movement; perform isometric contraction exercise of quadriceps without causing pain.

Day 2 through week 3: Continue the above exercises. Crutches were used to avoid touching the ground; gradually start leg muscle strengthening exercises with the goal of building up the atrophied thigh muscles.

Weeks 4 through 6: Start active ankle exercises such as bending and stretching, gradually increase workload and work range with the aim of having the activities of the affected ankle be the same as the unaffected one within a couple of months; start training with resistance and body weight shifting to gradually increase the load on the affected leg.

Normal walking is expected by the end of week six. Resistance training is introduced by bending or stretching the foot.

Results

The mean American Orthopedic Foot and Ankle Society Ankle Hindfoot score (AOFAS)[6]were used to evaluate the surgical outcomes as follows: An excellent result indicates complete pain relief or only slight pain. Normal activities and shoe wearing are possible. A fair result indicates significant pain relief with slight pain after extremely vigorous exercises. The patient should wear tight shoes. A pass result indicates slight pain relief; however, normal walking or wearing normal shoes is not possible.

All of the 23 patients underwent follow-up examination. The follow-up periods ranged from 8 to 26 months with a mean of 12 months. Radiography (Fig.4b) and MRI (Fig.4d) were compared with those of preoperative Radiography (Fig. 4a) and MRI (Fig. 4c).

Eighteen patients were post-operatively scored as excellent, 3 as fair, and 2 as pass; therefore, the excellent/fair rate was 91.3%. The mean pre-operative AOFAS score was 70 (range, 65–75). The mea post-operative score was 95 (range, 90–98). One patient complained of slight numbness of the medial side of anterior foot which almost completely disappeared after 3 months of nutritional management, neurological therapy, and exercises aimed at improving blood circulation. During the follow-up examinations, the range o motion of bending and stretching of the ankle joint was normal in all patients.

 

Discussion

Lateral ankle instability is common injury and can be categorized as


Figure 4. Radiography and MRI Comparsion before and after surgery. a) Preoperative radiography of the right ankle. b) Postoperative radiography of the right ankle. c) Preoperative MRI of the right ankle. d) Postoperative MRI of the right ankle.

 


functional instability (FI) based on patient complaints of having a weak or unstable foot [7]; while mechanical instability (MI) mainly referred to apparently loose ankle ligaments [8,9]. Upon our years experience, we found that our surgical method would help patients regain ankle stability. Moreover in recent years, we have achieved success in short-term outcomes by using a minimally invasive allograft tendon reconstruction in patients with chronic ankle lateral instability.

The lateral collateral ligaments are important structures that stabilize the ankle[10]. Most ankle sprain patients commonly experience sudden internal rotation with the ankle in a plantarflexed position, and the resultant strong stress results in injury to the lateral collateral ligament. The anterior talofibular ligament is voluntery to injure. Damage to the anterior talofibular ligament often develops into a chronic injury because of delayed treatment. Our surgery simultaneously reconstructed the anterior talofibular ligament and the calcaneofibular ligament. The reconstruction was relatively simple and resulted in significantly improved ankle stability. Most researchers agree that patients with injury to the lateral collateral ligament of the ankle should undergo surgical reconstruction to repair the ligaments anatomical structure and restore its normal tension, which is the anatomical basis of normal ankle proprioception[8]. Currently, the Watson-Jones or Chrisman–Snook procedures are commonly used to repair and reconstruct the lateral ankle ligament. These procedures use a full or partial peroneus brevis tendon graft[9]. In our opinion, it might compromise the function of the peroneus brevis tendon and reduce the external rotation strength of the ankle, which leads to ankle arthritis in the long term. Other techniques include using suture anchors to repair the lateral ankle ligament. These anchors are placed in the fibula and the injured ligament is sutured to them to achieve repair of the lateral collateral ligament. It has been thought that this method allows contact between the tendon and bone surface and eventually results in healing of the tendon-bone interface. We prefer the method for fresh injury. If it is chronic ankle latetral instability commonly more than 1 year, we will prefer surgical reconstruction in half tendon allograft. Injured ligaments may develop scars and contractures, and therefore the interface area resulting from the tendon-to-bone suturing may be very limited and have only weak tendon strength. Once the suture is broken or absorbed, recurrence of the lateral ankle instability may occur. Another technique uses the patellar ligament, which still attached to the patellar periosteum and a bone flap from the tibial tubercle, to reconstruct the lateral collateral ankle ligament [11]. In this technique the bone-tendon-periosteum graft is used to facilitate bone healing. However, the anterior talofibular ligament is very short, and therefore it is very difficult to obtain a graft of the proper length. Additionally, tendon harvesting introduces new injury, which can easily cause complications such as knee extensor injury or anterior patellar pain. In 2012, Hua Yinghui et al [12] reported the use of a half tendon autograft to reconstruct the lateral ankle ligament using unique tunneling technology with satisfactory surgical outcomes. Comparing with these methods [11,13-16], we believe that there are several advantages of our technique. First, it avoids other structural and functional injuries from tendon harvesting. The procedure is also simple and reliable, and both ends of the tendon are fixed in the bone tunnel, so the tendon-bone interface is large enough to obtain stable healing. Secondly, a minimally invasive surgery is applied, which shortens postoperative recovery. Finally, the diameter of the tendon allograft can reach 4.5 mm; therefore, the mass of the tendon graft is significantly greater than that of the anterior talofibular ligament, allowing enough strength to provide stability during exercise.

This study showed surgical reconstruction using a half tendon allograft had excellent outcome in lateral ankle ligament injuries. Patients recovered with full range of motion verified by post-operative physical examination as well imaging. Thus, surgical method presented here could be suitable for use in patients with chronic ankle instability due to lateral ankle ligament injury.

Acknowledgments

This study was supported by the Natural Science Foundation of China (81272017, 81201741).

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