Foot & Ankle
Ankle inversion is one of the most frequent injuries sustained with as many as three in ten thousand sustaining this injury each day.1 The majority settle with little treatment, however others may have ongoing problems of pain, swelling and instability. Physiotherapy programmes concentrate on swelling reduction, range of movement and strengthening functional neuromuscular control for the everting peroneal muscles. Patients with functional ankle instability have been shown to have deficits in peroneal latency and electromechanical delay,2 effectively arthrogenic inhibition. Rehabilitation aims to improve these deficits, however this alone may not protect the ankle form further episodes of instability.3
Surgical solutions to instability include a direct repair of injured structures, a localized reefing of healed elongated structures termed anatomic repair and reconstruction. The Broström reefing of the anterior talo-fibular ligament4 has recently been shown to improve function at 9 years but it this series there was a 16% failure and a quarter of patients had poor or fair outcome.5 ...
The use of other tissues to form a checkrein stabilizing the joint can be termed a non-anatomic repair. The techniques of the Evans, Watson-Jones and Chrisman Snook all sacrifice agonist evertors of the ankle, sub-talar and mid-foot joints and good outcome is reported.6-8 It does seem strange to sacrifice an agonist tendon to form an inert checkrein of tissue.
The use of free hamstring autograft has been described and shows good results. 9 The harvest is easily performed and patients rehabilitate quickly with minimal complications. The literature reports some weakness of flexion beyond 70˚, particularly when both gracilis and semitendinosus tendons are harvested.10 Patients may have some altered sensation in the distribution of the branches of the saphenous nerve and an oblique incision is recommended.11 Interestingly the hamstring muscles themselves are inhibited with chronic ankle instability12 although as yet there is no data on whether their harvest in cases of ankle instability has an effect on knee function.
This ligament reconstruction can be performed through small 5mm incisions effectively making it a minimally invasive procedure.13 The graft can then be inserted into bone tunnels in the calcaneum, fibula and talus to reconstruct the original ligaments. This leaves the stabilizing evertor muscles intact together with reconstructing the ATFL and calcaneno-fibular ligaments and so may also be considered to be an anatomic repair.
Mr Mike Carmont, Consultant Orthopaedic Surgeon, Princess Royal Hospital, Shropshire, UK
May 2013
References:
1. Swenson DM, Collins CL, Fields SK, Comstock RD. Epidemiology of US High School Sports-Related Ligamentous Ankle Injuries, 2005/06-2010/11. Clin J Sports Med 2013;23:190-196.
2. Hopkins JT, Brown TN, Christensen L, Palmieri-Smith RM. Deficits in peroneal latency and electromechanical delay in patients with functional ankle instability. J Orthop Res 2009;27:1541-1546.
3. Palmieri-Smith RM, Hopkins JT, Brown TN. Peroneal activation deficits in persons with functional ankle instability. Am J Sports Med 2009;37:982-988.
4. Broström L. Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures. Acta Chir Scand 1966;132:551-565.
5. Maffulli N, Del Buono A, Maffulli GD, et al. Isolated Anterior Talofibular Ligament Repair for Chronic Lateral Ankle Instability. Am J Sports Med 2013;41:858-864.
6. Bahr R, Pena F, Shine J, et al. Biomechanics of ankle ligament reconstruction: an in vitro comparison of the Broström repair, Watson-Jones reconstruction, and a new anatomic reconstruction technique. Am J Sports Med 1997;25:424-432.
7. Baltopoulos P, Tzagarakis GP, Kaseta MA. Midterm results of a modified evens repair for chronic lateral ankle instability. Clin Orthop Relat Res 2004;422:180-185.
8. Kramer D, Solomon R, Curtis C, Zurakowski D, Micheli LJ. Clinical results and functional evaluation of the Chrisman-Snook procedure for lateral ankle instability in athletes. Foot Ankle Spec 2011;4:18-28.
9. Coughlin MJ, Schenck RC Jr, Grebing BR, Treme G. Comprehensive reconstruction of the lateral ankle for chronic instability using a free gracilis graft. Foot Ankle Int 2004;25:231-241.
10. Ardern CL, Webster KE. Knee flexor strength recovery following hamstring tendon harvest for anterior cruciate ligament reconstruction: a systematic review. Orthop Rev (Pavia) 2009;1:e12.
11. Sabat D, Kumar V. Nerve injury during hamstring graft harvest: a prospective comparative study of three different incisions. Knee Surg Sports Traumatol Arthrosc 2012 [Epub ahead of print]. PMID: 23073817.
12. Sedary EJ, McVey ED, Cross KM, Ingersoll CD, Hertel J. Arthrogenic muscle response of the quadriceps and hamstrings with chronic ankle instability. J Athl Train 2007;42:355-360.
13. Wang B, Xu XY. Minimally Invasive Reconstruction of Lateral Ligaments of the Ankle Using Semitendinosus Autograft. Foot Ankle Int 2013 Feb 27 [Epub ahead of print].
