A Guide To Addressing Lateral Ankle Instability

Peter Walimire, DPM, Joshua Daly, DPM, MBA, and Joseph A. Conte, DPM

   Then place the foot in a dorsiflexed and everted position. Repair mid-substance ruptures of the ATFL and CFL primarily, utilizing non-absorbable suture in a “pants over vest” fashion. If a ligament has ruptured near its bony insertion, repair the ligament by inserting a soft tissue anchor into the bone. Take care to achieve physiologic tension on the ligament during the repair. Dissect the inferior extensor retinaculum, advance it proximally and suture it to the lateral joint capsule and periosteum of the lateral malleolus. This helps restore stability to both the ankle and subtalar joints.6

   Brostrom reported excellent results in his original articles, noting that 43 out of 60 patients reported complete resolution of symptoms and all but one patient achieved some improvement.20 Bell demonstrated 96 percent good to excellent outcomes in a 26-year follow-up with anatomic repair of the lateral ankle ligaments.21

   The literature has described arthroscopic repair of the ligament. Since the ATFL is intracapsular, one may visualize and repair it from inside the joint capsule. The advantage to arthroscopic repair includes the ability to visualize the joint surfaces and perform any necessary intra-articular repairs.

   Komenda and Ferkel found that 93 percent of ankles with lateral instability had associated intra-articular abnormalities, including loose bodies, synovitis, osteophytes, adhesions and chondromalacia.22 The techniques researchers have described for arthroscopic repair include arthroscopic stapling and thermal shrinkage utilizing monopolar radiofrequency.23 Ryan demonstrated good to excellent results in 11 out of 13 patients with functional instability following arthroscopic repair of the ATFL in an early follow-up cohort.24 Oloff also demonstrated a significant reduction in mechanical instability through preoperative and postoperative measurements of the talar tilt and anterior drawer tests following arthroscopic thermal assisted capsular shrinkage.5

What The Literature Reveals About Tenodesing Procedures

   Tenodesing procedures are indicated when delayed primary repair has failed, in patients weighing greater than 250 pounds, and if patients have experienced instability for greater than 10 years.25,26 These procedures attempt to stabilize the lateral ankle using either tendon autograft or allograft. A common complication of tenodesis procedures is restriction of subtalar joint inversion. However, this aids in the stability of the lateral ankle following the repair.4

   Traditionally performed, autograft procedures commonly involve harvesting the peroneus brevis, peroneus longus, plantaris or Achilles tendons, often in a split fashion, and rerouting it throughout the lateral ankle.12 These procedures create non-anatomic repairs but have the benefit of using vascularized structures with no risk of foreign body rejection or inflammatory reaction.

   Allograft procedures are increasingly being incorporated into the surgical options for the unstable ankle patient, possibly due to the increased availability of donor tendon grafts. Although they carry with them the inherent risks mentioned above, allografts also have the benefit of allowing for an anatomic repair since they are not limited by origin or insertion of the natural tendon structures.27

   For both autograft and allograft procedures, researchers have described numerous techniques, which can generally be divided into single or double ligament reconstruction.

   Single ligament reconstruction procedures include the Watson-Jones, Lee and Evans procedures. There have been mixed results in the literature with these repairs. Peters performed a retrospective review of 250 Watson-Jones stabilizations in 250 ankles and demonstrated that 95 percent of patients regained stability and 80 to 85 percent had good to excellent outcomes.12 A long-term retrospective study of nine patients with an average of 22 years follow-up who underwent the Watson-Jones procedure demonstrated loss of stability in six patients.28 Other authors have also noted loss of stability following single ligament tenodesis procedures.29-31

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