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.
Take care to retract the superficial peroneal nerve branches. Use a #15 blade to perform sharp dissection to release both the ATF and CF ligament off the tip of the lateral malleolus. Try to preserve their attachment to the talus and calcaneus to help with proper placement of the graft. At this point, you should have adequate exposure to the lateral aspect of the body-neck junction of the talus, the distal portion of the lateral malleolus and the lateral wall of the calcaneus just inferior and posterior to the critical angle of Gissane.
During dissection, the allograft should be thawing on the back table. Peroneus longus allograft works well. The graft length is between 19 and 22 cm. This will provide enough for two grafts if necessary. Cut the graft into two 10-cm pieces. The reconstruction begins at the tip of the lateral malleolus. Position one end of the graft into the tip of the lateral malleolus and secure it with a bio-tenodesis screw. Start just anterior to the tip of the malleolus and orient the tunnel slightly posterior as you advance the tunnel superiorly.
There are two key points here. First, take care to avoid using too large of a screw and splitting the lateral malleolus. A 6- or 7-mm diameter screw works well. Second, do not aim too horizontal to exit the posterior aspect of the malleolus. The tunnel is primarily a superior direction.
Once the proximal portion of the reconstruction is stable, start on the two distal attachments. At this point, fluoroscan is recommended on the patient’s original ligaments to help identify the proper location for the insertion of the allograft. Split the allograft longitudinally so it has a “Y” shape as it exits the tip of the lateral malleolus. Position the foot in a dorsiflexed and everted position. Create a tunnel under the peroneal tendons and pass the posterior arm of the allograft under the tendons.
With the foot everted, secure the allograft into the calcaneus with a bio-tenodesis screw oriented lateral to medial. This is typically a 5- or 6-mm screw. While maintaining the foot position, insert the anterior arm of the allograft into the talus from lateral to medial. The length of the screw into the calcaneus is 20 to 25 mm and the length of the screw into the talus is 10 to 15 mm.
Avoid making the allograft too long. If the allograft is too long, it will “bunch” up in the osseous tunnel and the surgeon will not be able to tension this properly with the bio-tenodesis screw. As the surgeon tightens the screw, the allograft should be tight. If it is not tensioning as one tightens the screw, remove the screw and trim some of the graft so it is shorter.
Check the reconstruction by lifting the leg off the table. The heel should stay in a neutral position. My personal philosophy with this repair is better too tight than too loose. Perform layered closure with the capsule. Place the leg in a splint with slight eversion and dorsiflexion.
Pertinent Insights On The Post-Op Course
Place the patient in a non-weightbearing compression splint for two weeks. The position of the splint is everted and dorsiflexed. The patient then wears a walking cast for two weeks. Then advance the patient to a walking boot for four weeks. I also recommend a night splint during this period of time. Patients can start range of motion exercises. At eight weeks post-op, the patient can wear a shoe with an ankle brace when walking outside.
Physical therapy can also start at this time. The physical therapist must be aware of the extent of the surgery and not treat this like a typical ankle sprain. Return to sports takes about four months on average. I recommend the use of an ankle brace with return to sports for at least six to nine months.
Dr. Grambart is the foot and ankle surgeon for the Division of Orthopedics at the Carle Clinic Association in Champaign, Ill. He is a Clinical Instructor at the University of Illinois School of Medicine. Dr. Grambart is a Fellow of the American College of Foot and Ankle Surgeons.
1. Komenda GA, Ferkel RD. Arthroscopic findings associated with the unstable ankle. Foot Ankle Int 1999; 20(11):708–13.
2. Sammarco VJ. Complications of lateral ankle ligament reconstruction. Clin Orthop 2001; 391(10):123–32.
3. Evans DL. Recurrent instability of the ankle and method of surgical treatment. Proc R Soc Med 1953; 46(5):343–4.
4. Chrisman OD, Snook GA. Reconstruction of lateral ligament tears of the ankle. An experimental study and clinical evaluation of seven patients treated by a new modification of the Elmslie procedure. J Bone Joint Surg Am 1969; 51(5):904–12.
5. Zenni EJ Jr, Grefer M, Krieg JK, et al. Lateral ligamentous instability of the ankle: a method of surgical reconstruction by a modified Watson-Jones technique. Am J Sports Med 1977; 5(2):78–83.
6. Hedeboe J, Johannsen A. Recurrent instability of the ankle joint. Surgical repair by the Watson-Jones method. Acta Orthop Scand 1979; 50(3):337–40.
7. Horstman JK, Kantor GS, Samuelson KM. Investigation of lateral ankle ligament reconstruction. Foot Ankle 1981; 1(6):338–42.
8. Becker HP, Rosenbaum D, Zeithammer G, Gerngross H, Claes L. Gait pattern analysis after ankle ligament reconstruction (modified Evans procedure). Foot Ankle Int 1994; 15(9):477-482.
9. Rosenbaum D, Becker HP, Wilke HJ, et al. Tenodeses destroy the kinematic coupling of the ankle joint complex: a three-dimensional in vitro analysis of joint movement. J Bone Joint Surg 1998; 80(1):162–8. 10. Rosenbaum D, Bertsch C, Claes LE. Tenodeses do not fully restore ankle joint loading characteristics: a biomechanical in vitro investigation in the hind foot. Clin Biomech (Bristol) 1997; 12(3):202–9. 11. Indelli PF, Dillingham MF, Fanton GS, et al. Anterior cruciate ligament reconstruction using cryopreserved allografts. Clin Orthop 2004; 420:268–75.