A Closer Look At Allografts For Lateral Ankle Ligament Reconstruction

Author(s): 
Sean Grambart, DPM

Fifteen to 25 percent of all injuries involving the human musculoskeletal system are reportedly sprains of the lateral ankle ligaments.1 The majority of patients with ankle sprains have excellent results following surgical treatment but 20 to 40 percent of patients with severe ankle sprains will have continued pain and instability.2

   Primary repair typically consists of a Brostrom procedure involving the anterior talofibular ligament. There is debate on the optimal surgical treatment of choice for patients with chronic ankle instability. Researchers have described many procedures in the literature for patients with recurrent injury.3-9 Procedures range from primary end to end repair of the ligaments to ligament reconstruction with tendon grafts.

   The ideal reconstruction of the lateral ankle ligaments should attempt to restore the normal ankle anatomy and function. Many of the aforementioned procedures sacrifice normal tissue and are not anatomic reconstruction. This may disrupt the normal kinematics of the joints.10

   Allograft tissue offers advantages such as shorter operative time, no donor site morbidity, better availability of grafts, decreased incidence of arthrofibrosis and fewer postoperative complications. Disadvantages include risk of disease transmission, the potential for subclinical immune response and increased cost.11

   This article describes the surgical technique for the anatomic reconstruction of the anterior talofibular and calcaneofibular ligament using a peroneal tendon allograft.

What Are The Indications For Lateral Ankle Ligament Repair?

The main surgical indication for any lateral ligament procedure is failure of conservative treatment and the inability of the patient to perform normal activities due to pain or instability. The exceptions to the rule are elite level athletes, in whom repair of the injured ligament as soon as possible is recommended.

   During the initial consultation with patients, pertinent questions would include ascertaining the length of time they have had instability and the number of “bad” sprains they have had that prohibited walking immediately afterward.

   The question now becomes primary repair (Brostrom) versus lateral ligament reconstruction. The main indication for a primary repair is a single ligament injury. Traditionally, the indication for a lateral ankle ligament reconstruction has been failure of an attempted primary repair and/or a patient weighing greater than 250 pounds.

   I have also found that patients with generalized ligament laxity with injury to both the anterior talofibular ligament (ATF) and calcaneofibular (CF) ligaments fare poorly with a primary repair. With any surgical reconstruction of the ligaments, the surgeon must address any underlying structural deformities such as hindfoot varus, a plantarflexed medial column and underlying muscle instability.

Step-By-Step Surgical Pointers

Patient positioning is based on what adjunctive procedures are necessary. Surgeons should perform osseous procedures first to correct the foot structure. When utilizing ankle arthroscopy, I start with the patient in a supine position, perform the arthroscopy and any medial column work, and then switch to a lateral decubitus position. Placing a sterile sleeve over the operative leg and re-draping and prepping when going lateral is recommended.

   The incisional approach depends on whether you need to perform any procedures at the lateral calcaneus. Utilize a two-incision approach if a lateralizing calcaneal osteotomy is needed. Place one incision as you normally would for the osteotomy. Place the other incision along the anterior aspect of the lateral malleolus, curving distally and inferior to the tip of the lateral malleolus. With a ligament reconstruction only, a single “J” incision approach starting along the lateral malleolus and extending medially allows for good exposure.

Comments

Does this also apply to lateral ligament laxity caused by ill conceived and executed surgeries for flatfoot and/or subtalar fusion solely for the purpose of correcting a valgus heel position?

I understand that you have no problem removing fusion rods that prohibit the predetermined need for the Inbone. May we hear about that please?

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