Revisiting A Proven Approach To Severe Ankle Instability

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The author prefers making a “hockey stick” incision that begins approximately 6 cm superior and posterior to the distal tip of the fibula and extends to the base of the fifth metatarsal.
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Author(s): 
By Jesse Burks, DPM

   The peroneus brevis lies slightly superior and lateral to the peroneus longus. With the aforementioned incision, one can easily trace the peroneus brevis from the fifth metatarsal base. Surgeons can split the brevis longitudinally or harvest the entire brevis. If you harvest the entire brevis, leave it intact distally and suture the proximal stump to the longus tendon. A number of suture techniques are available for securing the end of the brevis to be transferred. With this technique, one should focus on forming the end into a tight cylinder shape that will not fray. Lay the tendon aside and wrap it in a moist gauze.

   At this point, one should easily identify the distal tip of the fibula and dissection is not necessary for performing the drill hole. Employing a 4-mm drill is often adequate to accommodate the tendon, but one may adjust this based on the circumference of the tendon harvested. Surgeons should always begin with a small drill and gradually increase the diameter, usually placing it approximately 1 cm superior to the distal tip. One of the most common mistakes in creating the tunnel is moving too far laterally and violating the lateral cortex. If this occurs, I have found employing a soft tissue anchor secures the tendon at this point with no detrimental consequences to the procedure.

   A second mistake is directing the drill bit too medially and entering the lateral gutter of the ankle joint. Using intraoperative fluoroscopy is imperative during this portion of the procedure. Then pass the brevis tendon anterior to posterior through the fibula.

   Occasionally, surgeons may find there is insufficient length to attach the tendon into the lateral wall of the calcaneus. Often this may be due to insufficient length of the original incision. If this occurs, one may split the tendon longitudinally and secure it with a suture at the point where it passes through the fibula.

   Originally, surgeons secured the free end of the brevis into the lateral wall of the calcaneus by creating a drill hole just beneath the cortical wall. Now a soft tissue anchor serves this purpose just as well.

Key Pointers On Postoperative Care

   Immobilization in a short leg cast or splint is usually advisable for four weeks. Some authors recommend six weeks but in my experience, the two extra weeks of strict immobilization contributes to a greater amount of ankle stiffness. Following the initial four weeks, the patient should continue weightbearing in a removable cast walker for an additional four weeks. Physical therapy is at the surgeon’s discretion, but I have often found it helpful with these procedures, due to significant edema and a decreased in ankle joint range of motion.

   While the modified Christman and Snook (Winfield) ankle stabilization is an older procedure, it remains a very effective surgical technique for addressing severe ankle instability.

Dr. Burks is a Fellow of the American College of Foot and Ankle Surgeons and is board certified in foot and ankle surgery. Dr. Burks practices in Little Rock, Ark.

Editor’s Note: For related articles, see “Detecting The Cause Of Chronic Ankle Pain” on page 68 of the March 2002 issue or “How To Manage Lateral Ankle Sprains” on page 56 of the November 2003 issue. Also check out the archives at www.podiatrytoday.com.

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