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Accelerated Versus Traditional Rehabilitation After Anterior Talofibular Ligament Reconstruction for Chronic Lateral Instability of the Ankle in Athletes Wataru Miyamoto, Masato Takao, Kazuaki Yamada and Takashi Matsushita Am J Sports Med 2014 42: 1441 originally published online April 10, 2014 DOI: 10.1177/0363546514527418 The online version of this article can be found at: http://ajs.sagepub.com/content/42/6/1441
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Accelerated Versus Traditional Rehabilitation After Anterior Talofibular Ligament Reconstruction for Chronic Lateral Instability of the Ankle in Athletes Wataru Miyamoto,*y MD, Masato Takao,y MD, Kazuaki Yamada,y MD, and Takashi Matsushita,y MD Investigation performed at Teikyo University School of Medicine, Tokyo, Japan Background: Although several reconstruction procedures for chronic lateral ankle instability using autografts have been reported, all have recommended postoperative immobilization and a nonweightbearing period. Hypothesis: Reconstructive surgery with a gracilis autograft using an interference fit anchoring system for chronic lateral ankle instability enables early accelerated rehabilitation and recovery with a return to activity without requiring immobilization. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 33 patients (33 feet) who underwent reconstruction of the anterior talofibular ligament with a gracilis autograft using interference screws were included; 15 were followed for 4 weeks with postoperative cast immobilization (group I), while 18 were followed with accelerated rehabilitation without immobilization (group A). Clinical and radiological results were evaluated based on the Karlsson and Peterson score, talar tilt angle, anterior displacement of the talus on stress radiography, and time between surgery and return to full athletic activity. Results: The mean Karlsson and Peterson scores before and 2 years after surgery were the following: for group I: 62.3 6 4.7 (range, 54-72) and 94.4 6 7.1 (range, 76-100), respectively (P \ .001), and for group A: 64.1 6 4.8 (range, 57-70) and 91.7 6 7.7 (range, 74100), respectively (P \ .001). The mean difference in the talar tilt angle compared with the contralateral side and mean displacement of the talus on stress radiography before and 2 years after surgery were the following: for group I: 8.7° 6 2.6° and 7.7 6 1.8 mm and 3.8° 6 1.5° and 4.0 6 1.6 mm, respectively, and for group A: 10.5° 6 3.4° and 8.7 6 2.1 mm and 4.3° 6 1.8° and 4.3 6 1.2 mm, respectively. Radiography revealed significantly improved postoperative outcomes in both groups (P \ .0001). No significant differences in the score and any parameters on stress radiography were evident at 2 years after surgery between the groups. The mean time between surgery and return to full athletic activity was significantly higher in group I (18.5 6 3.5 weeks) than in group A (13.4 6 2.2 weeks) (P \ .0001). No cases of reinjury were reported, and no differences in athletic performance ability were observed between the groups. Conclusion: Patients in group A returned to full athletic activity 5 weeks earlier than those in group I, demonstrating the advantage of accelerated rehabilitation after surgery. Keywords: ankle; lateral ligament; accelerated rehabilitation; reconstructive surgery
Several studies have shown that approximately 20% of patients with ankle inversion sprains did not achieve
good clinical outcomes even after adequate nonsurgical treatment and complained of persistent lateral ankle instability.6,12,26,27 Persistent pain, recurrent sprains, and repeated instances of the ankle giving way are hallmarks of chronic lateral instability of the ankle joint, and surgical treatment is indicated if such symptoms affect a person’s daily or sports activities.19 Although many types of surgical procedures for chronic lateral ankle instability exist, the majority of patients have been treated successfully by means of Brostro¨m-type anatomic repair, and only cases with insufficient remnants of the lateral ankle ligaments, which are not suitable for anatomic repair, need to undergo alternative reconstructive procedures. With regard to such alternative procedures, the recent trend is toward
*Address correspondence to Wataru Miyamoto, MD, Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan (e-mail: [email protected] kyo-u.ac.jp). y Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. The American Journal of Sports Medicine, Vol. 42, No. 6 DOI: 10.1177/0363546514527418 Ó 2014 The Author(s)
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anatomic reconstruction using autogenous grafts instead of tenodesis stabilization procedures, such as those of WatsonJones, Evans, and Christman-Snook.7,10,14,23,24,28,29 Recently, several autogenous grafts such as the semitendinosus tendon, gracilis tendon, plantaris tendon, toe extensor tendon, and bone–patellar tendon have been used for reconstruction of the lateral ligaments of the ankle joint, and these grafts are optimally fixed to the anatomic bone attachment points of the lateral ligaments by means of various fixation devices.1,7,10,14,23,24,28,29 In reconstructive surgery for chronic lateral ankle instability, all reported procedures using autografts involved a period of immobilization and nonweightbearing after surgery because these are time-honored procedures and the initial fixation strength of the autograft by fixation devices seems to be insufficient for early range of motion exercises or weightbearing.1,7,10,14,23,24,28,29 Since 2001, we have been performing anatomic reconstruction of the lateral ligaments of the ankle with a gracilis autograft using an interference fit anchoring system for chronic lateral ankle instability. Initially, cast immobilization of the operated ankle for 4 weeks and nonweightbearing activity for 2 weeks were used for the postoperative protocol. However, because recent biomechanical studies on interference screws have shown sufficient initial fixation strength of the bone-autograft attachment13,20 with respect to earlier rehabilitation, we hypothesized that reconstructive surgery with a gracilis autograft using an interference fit anchoring system enables early accelerated rehabilitation without immobilization of the operated ankle. Such an intervention has an obvious advantage, especially for sports athletes wishing to return to full athletic activity as early as possible. The purpose of this study was to investigate and compare clinical outcomes after reconstructive surgery with (1) the patient subjected to immobilization and delayed range of motion and weightbearing exercises and (2) the patient subjected to early accelerated rehabilitation without immobilization and also to evaluate the efficacy of early accelerated rehabilitation without immobilization for sports athletes with chronic lateral ankle instability.
MATERIALS AND METHODS Patients Between January 2007 and March 2010, a total of 69 athletes who experienced an inversion ankle sprain at least once during their sports activities and who had chronic ankle pain accompanied by a repetitive sense of the ankle giving way for more than 6 months visited our institution. On physical examination, all patients complained of pain when palpated at the anterior aspect of the lateral malleolus, and they also showed manual anterior drawer laxity. Talocrural instability was diagnosed by means of the varus stress test and the anterior drawer test of the talocrural joint using a Telos device (Telos SE 2000, Telos GmbH, Marburg, Germany) with a force of 50 N. A diagnosis of talocrural instability was made on detection of instability
with a talar tilt angle 5° compared with the contralateral side by the varus stress test and/or anterior talar displacement 6 mm by the anterior drawer test. In addition, stress radiography of the subtalar joint, reported by Yamamoto et al,32 was performed to evaluate the function of the calcaneofibular ligament (CFL). If the talocalcaneal angle was less than 10°, the subtalar joint was diagnosed as stable with an intact CFL. However, if a talocalcaneal angle of more than 10° was noted, the subtalar joint was diagnosed as unstable, indicating reconstruction of not only the anterior talofibular ligament (ATFL) but also the CFL. Furthermore, magnetic resonance imaging (MRI) was performed in all patients to evaluate complicated injuries including fractures, tendon injuries, and osteochondral lesions. Inclusion criteria were as follows: (1) talocrural instability on stress radiography of the talocrural joint, (2) stable subtalar joint on talocalcaneal stress radiography showing no need for CFL reconstruction,32 (3) no concomitant disorder confirmed on MRI, (4) no previous surgery on the affected lower extremity, (5) a healthy contralateral ankle, and (6) no response to nonoperative therapy for more than 3 months. Of the 69 patients, 33 (23 male and 10 female; 33 feet) patients who met the inclusion criteria were included. Institutional review board approval for this study and informed consent from all patients were obtained. Patients were divided into 2 groups after they approved the suggested procedure by filling out a special consent form. If the patient’s first examination at our institution occurred on an even-numbered day, the patient underwent reconstruction of the ATFL followed by postoperative cast immobilization of the operated ankle for 4 weeks (group I). If the first examination occurred on an odd-numbered day, the patient was treated by ATFL reconstruction with accelerated rehabilitation without postoperative immobilization (group A). Group I comprised 15 patients (10 male and 5 female; 15 feet) whose age at the time of surgery ranged from 18 to 43 years (mean, 27.7 6 8.1 years). Group A comprised 18 patients (13 male and 5 female; 18 feet) whose age at the time of surgery ranged from 21 to 40 years (mean, 26.4 6 5.2 years). Symptom duration ranged from 3 to 11 months (mean, 5.9 6 4.8 months) in group I and from 3 to 10 months (mean, 6.3 6 2.0 months) in group A. In each group, anatomic reconstruction of the ATFL was performed by applying an interference fit anchoring system with a gracilis autograft. No differences (major or subtle) in the surgical procedure were noted between the 2 groups.
Surgical Technique A gracilis tendon of the ipsilateral knee was harvested using a tendon harvester inserted through a medial knee skin incision of approximately 3 cm in length. A 9-cm segment of the harvested gracilis tendon was manufactured into an autograft and shaped into a useable form for reconstruction of the ATFL (Figure 1). Next, under a pneumotourniquet inflated to a pressure of approximately 300 mm Hg, a straight skin incision of approximately 3.5 cm in length was initiated at the tip of the distal fibula and continued in the anterior direction. The anterior border of the lateral malleolus was identified, and the ankle
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Figure 1. Gracilis tendon manufactured from an autograft harvested from the ipsilateral knee.
Figure 3. Overdrilling along the guide wire to create a bone tunnel to a depth of more than 20 mm with a cancellous bone–harvesting drill with a bit diameter of 6.5 mm.
Figure 2. Insertion of the guide wires through the fibular attachment and the talar attachment of the anterior talofibular ligament.
joint was opened both proximal and distal to the ATFL to prevent damage to the superficial peroneal nerve. After removal of the ATFL remnant, a guide wire was used to penetrate the fibula through the fibular attachment of the ATFL toward the proximal and posterior areas of the fibula, creating an angle of approximately 20° to the fibula’s axis. In addition, a guide wire was used to penetrate the talus through the talar attachment of the ATFL toward the distal posterior end of the medial malleolus (Figure 2). Along these guide wires, overdrilling was performed to create a bone tunnel to a depth of more than 20 mm using a cancellous bone–harvesting drill with a bit diameter of 6.5 mm (Meira Co Ltd, Nagoya, Japan). This drill, as its name implies, is used to harvest cylindrical cancellous bone during overdrilling (Figure 3). The ends of the
Figure 4. Insertion of each autograft end into the bone tunnel by means of a thread and pierced guide wire from the inside to the outside.
manufactured autograft were pulled through both bone tunnels from the inside to the outside by using a thread and pierced guide wire, such that the thread lay at the exit of each bone tunnel and passed through the skin (Figure 4). Then, each tunneled end of the autograft was fixed with a 5.0-mm interference screw (Tendon-Junction screw, Meira Co Ltd), with the ankle in the neutral position, using the pieces of cancellous bone that were cut from the harvested cancellous bone cylinder between the screw and each end of the autograft, and a load of approximately
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Figure 5. (A) Anatomic reconstruction of the anterior talofibular ligament (ATFL) using an interference fit anchoring system with a gracilis autograft. (B) Intraoperative photograph showing the implanted autograft. (C) Postoperative radiograph showing adequate positioning of each interference screw at the fibular and talar attachments of the ATFL. at 6 to 7 weeks after surgery in group I and at 2 to 3 weeks after surgery in group A. In both groups, patients were allowed to jog as soon as they achieved full weightbearing without pain, and if they could jog without pain, they were allowed to run. Return to training and finally full return to their preinjury sports activities were allowed when they experienced no difficulties in their sport-specific drills and when they were confident to return.
Evaluation
Figure 6. Postoperative rehabilitation program in group I with cast immobilization and in group A with accelerated rehabilitation without cast immobilization. ROM, range of motion. 30 N was manually applied to create tension in the autograft during screw fixation (Figure 5).
The clinical results of all patients were evaluated using the Karlsson and Peterson scoring system17 before surgery and at 2 years after surgery. Patients also underwent standard stress radiography of the talocrural joint at the same time to evaluate improvement in the talar tilt angle and anterior displacement of the talus, and results were compared with those obtained before surgery. In addition, the time between surgery and return to athletic activity, defined as a return to near preinjury performance levels, was investigated in each group.
Postoperative Management In group I, the operated ankle was immobilized with a short leg cast for 4 weeks, followed by application of a soft ankle orthosis for 4 weeks. Two weeks after surgery, weightbearing was allowed with the ankle cast on, and at 4 weeks after surgery, full weightbearing was allowed while wearing a soft ankle orthosis. Exercises to restore motion and strength conducted by a physical therapist began after cast removal. In group A, a soft ankle orthosis was applied immediately after surgery for 8 weeks, and weightbearing was allowed without restriction in accordance with the patient’s ability to endure. Exercises to restore motion and strength conducted by a physical therapist began 2 days after surgery. In both groups, all patients removed the soft ankle orthosis 8 weeks after surgery (Figure 6). Endurance training on a treadmill, sport-specific drills, and training to improve balance on a balance board began
Statistical Analysis Intraclass correlation coefficients (ICCs) were used to test the intraobserver and interobserver reliability of the radiological measurements, including the talar tilt angle and anterior displacement of the talus. Differences in the talar tilt angle compared with the contralateral side, displacement of the talus, and Karlsson and Peterson scores before surgery and at 2 years after surgery were assessed using the paired t test. Furthermore, differences in the talar tilt angle compared with the contralateral side, displacement of the talus, Karlsson and Peterson scores, and the time between surgery and return to full sports activities were assessed in both groups using the Mann-Whitney U test. P \ .05 was regarded as significant. All statistical analyses were performed with StatView software (version 5.0, Abacus Concepts, Berkeley, California, USA).
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TABLE 1 Treatment Outcomesa
Group I Karlsson and Peterson score Talar tilt angle compared with contralateral side, deg Anterior displacement of the talus, mm Group A Karlsson and Peterson score Talar tilt angle compared with contralateral side, deg Anterior displacement of the talus, mm
Before Surgery
2 Years After Surgery
P Value
62.3 6 4.7 (54-72) 8.7 6 2.6 (7-16) 7.7 6 1.8 (6-12)
94.4 6 7.1 (76-100) 3.8 6 1.5 (1-6) 4.0 6 1.6 (2-8)
\.0001 \.0001 \.0001
64.1 6 4.8 (57-70) 10.5 6 3.4 (6-15) 8.7 6 2.1 (6-13)
91.7 6 7.7 (74-100) 4.3 6 1.8 (2-6) 4.3 6 1.2 (3-7)
\.0001 \.0001 \.0001
a
Values are expressed as mean 6 standard deviation (range).
RESULTS
DISCUSSION
All patients were followed for 2 years. The mean Karlsson and Peterson scores of group I improved significantly from 62.3 6 4.7 (range, 54-72) before surgery to 94.4 6 7.1 (range, 76-100) at 2 years after surgery (P \ .0001). Similarly, the mean Karlsson and Peterson scores of group A improved significantly from 64.1 6 4.8 (range, 57-70) before surgery to 91.7 6 7.7 (range, 74-100) at 2 years after surgery (P \ .0001). There were no significant differences in the mean Karlsson and Peterson score at 2 years after surgery between the groups (P = .2523). The ICC for the intraobserver and interobserver reliability of the radiological measurement of the talar tilt angle was 0.987 and 0.987, respectively. Furthermore, the ICC for the intraobserver and interobserver reliability of the radiological measurement of anterior displacement of the talus was 0.955 and 0.972, respectively. In group I, the mean difference in the talar tilt angle compared with the contralateral side and mean anterior displacement of the talus on stress radiography were 8.7° 6 2.6° (range, 7°-16°) and 7.7 6 1.8 mm (range, 6-12 mm) before surgery and 3.8° 6 1.5° (range, 1°-6°) and 4.0 6 1.6 mm (range, 2-8 mm) at 2 years after surgery, respectively. In group A, the mean difference in the talar tilt angle and mean displacement of the talus on stress radiography were 10.5° 6 3.4° (range, 6°-15°) and 8.7 6 2.1 mm (range, 6-13 mm) before surgery and 4.3° 6 1.8° (range, 2°-6°) and 4.3 6 1.2 mm (range, 3-7 mm) at 2 years after surgery, respectively. The talar tilt angle and displacement of the talus were significantly improved after surgery in both groups (P \ .0001) (Table 1). There were no significant differences between the groups for the talar tilt angle (P = .1634) and displacement of the talus (P = .2318) at 2 years after surgery. All patients were able to return to their previous athletic activities, and the mean time between surgery and return to athletic activity was 18.5 6 3.5 weeks (range, 10-23 weeks) in group I and 13.4 6 2.2 weeks (range, 10-18 weeks) in group A, showing significant differences between the groups (P \ .0001). No surgical complications such as a superficial or deep infection, a nerve injury, or deep vein thrombosis were seen in any cases in either group. No cases of reinjury were reported, and no differences in performance ability were observed between the groups.
The gold standard for surgically treating chronic lateral instability of the ankle joint has been anatomic repair using remnants of the lateral ankle ligaments, and favorable long-term outcomes with good clinical prognosis have been reported after performing a modified Brostro¨m procedure.4,11,16 Furthermore, arthroscopic-assisted procedures that are less invasive than the conventional Brostro¨m procedure have been developed.9,21 However, for cases with insufficient remnants of the lateral ankle ligaments, which are not suitable for anatomic repair, anatomic reconstruction using autogenous grafts has been the main alternative procedure. Several reported reconstructive procedures have used autologous tendons such as the semitendinosus tendon, gracilis tendon, plantaris tendon, toe extensor tendon, and bone–patellar tendon as grafts for chronic lateral instability of the ankle joint.1,7,10,14,23,24,28,29 In these procedures, harvested autologous tendons are manufactured into autograft substitutes and fixed to both bone attachment points of the lateral ligaments by means of fixation devices.1,7,10,14,23,24,28,29 Several fixation devices and techniques such as a screw with a spiked washer, a bone suture anchor, an interference screw, and suturing are described in the literature, and all have good clinical outcomes.1,7,10,14,23,24,28,29 However, previously reported reconstructive procedures involving an autograft need a period of immobilization of the operated ankle joint as well as nonweightbearing activity on the lower extremity, and they never permit patients to perform accelerated postoperative range of motion exercises or early weightbearing activity.1,7,10,14,23,24,28,29 The most likely reason for this seems to be insufficient initial fixation strength for attaching the autograft to the bone attachment point with fixation devices for accelerated rehabilitation, although the initial fixation provided by different types of fixation devices has not been precisely investigated. On the other hand, previous studies have shown the undesired effects of joint immobilization on the ligament, capsule, musculature, periarticular bone, and articular cartilage.5,8,15,25 To avoid such effects, it is preferable to perform early accelerated joint motion and weightbearing without joint immobilization after joint surgery, and as
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expected, such rehabilitation after surgery seems to be most suitable after reconstructive surgery for chronic lateral ankle instability. The use of interference screws as an effective means of securing free grafts in bone tunnels has been widely advocated in anterior cruciate ligament reconstruction, and strong initial strength to fix free grafts in bone tunnels by means of interference screws with a large diameter has been reported by many investigators.18,30,31 Recently, because of the addition of a small-diameter version of the interference screw, clinical application of the interference screw has been further broadened to ligament reconstruction of the ankle, the patellofemoral joint, and the upper extremities, and subsequent mechanical analyses of small-diameter interference screw fixation strength have been reported.13,20 Jeys et al13 studied the biomechanical characteristics of a common bone suture anchor and a small interference screw with a diameter of 5.5 mm (Arthrex Inc, Naples, Florida, USA) by using a porcine bone and tendon model to represent ankle ligament reconstruction. In their study, the diameter of the created bone tunnel for fixation of the free graft by means of 5.5-mm interference screws was also 5.5 mm. Their study revealed that single pullto-failure testing of interference screws produces a mean load of 227 N, which was significantly greater than that of the bone suture anchors.13 Furthermore, Matsumoto et al20 studied the effect of the graft/bone tunnel crosssectional area ratio (GTR) to determine the initial fixation strength of small-diameter interference screws by using porcine knees and a patellar tendon. In their study, 2 bone tunnels with diameters of 4.5 or 5.0 mm were created, and a 4.0 mm–diameter interference screw was used.20 The results showed that the optimal GTR ranged from 60% to 90% and that the mean failure load was approximately 180 N for both bone tunnels if the host bone had a bone mineral density greater than 0.6 g/cm2.20 The initial fixation strengths of these small-diameter interference screws exceeded the mean load to failure of the ATFL, which is known from previous studies to be approximately 139 N.2,3 In the present study, the ipsilateral gracilis tendon was harvested as an autograft, and an interference screw with a diameter of 5.0 mm was used to fix the autograft to 5.5 mm–diameter bone tunnels, which were created at each bone attachment point of the ATFL. The gracilis tendon has sufficient tensile strength for reconstruction of the ATFL because the maximum failure load of the gracilis tendon is approximately 838 N.22 Furthermore, even if the harvested gracilis tendon is narrow and does not have a sufficient diameter to occupy 60% of the GTR, cancellous bone chips, which are inserted into the bone tunnel to protect the autograft from direct disruption by the screw and to develop an autograft–bone tunnel interface, can compensate for the occupation of the cross-sectional area. Of note, the cross-sectional area was insufficient in the gracilis autograft only, and all patients could achieve an optimal GTR after the autograft and placement of cancellous bone chips. Such a system enabled accelerated rehabilitation without immobilization after reconstructive surgery for chronic lateral ankle instability. In fact, patients in group A were able to return
to full sports activities significantly earlier (5 weeks) than those in group I and showed similar stability and clinical outcomes to those in group I at 2 years after surgery. This clearly demonstrates the disadvantage of immobilization and the advantage of accelerated rehabilitation after surgery. Accelerated rehabilitation is preferable if the initial fixation strength of the autograft is sufficiently confirmed. There are several limitations to this study. The sample population was small in both groups, and chronic lateral instability of the ankle joint due to injury of only the ATFL was evaluated. It is therefore necessary to evaluate the efficacy of the present procedure in a larger sample population undergoing accelerated rehabilitation. Moreover, evaluating long-term outcomes through follow-up is necessary to reveal the continuous effectiveness of the present procedure.
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17. Karlsson J, Peterson L. Evaluation of ankle joint function: the use of a scoring scale. Foot. 1991;1:15-19. 18. Kurosaka M, Yoshiya S, Andrish JT. A biomechanical comparison of different surgical techniques of graft fixation in anterior cruciate ligament reconstruction. Am J Sports Med. 1987;15:225-229. 19. Maffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop Surg. 2008;16:608-615. 20. Matsumoto A, Yoshiya S, Muratsu H, et al. Mechanical evaluation of a soft tissue interference screw with a small diameter: significance of graft/bone tunnel cross-sectional area ratio. Knee Surg Sports Traumatol Arthrosc. 2006;14:330-334. 21. Nery C, Raduan F, Del Buono A, Asaumi ID, Cohen M, Maffulli N. Arthroscopic-assisted Brostro¨m-Gould for chronic ankle instability: a long-term follow-up. Am J Sports Med. 2011;39:2381-2388. 22. Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy MS. Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Joint Surg Am. 1984;66:344-352. 23. Okuda R, Kinoshita M, Morikawa J, Jotoku T, Abe M. Reconstruction for chronic lateral ankle instability using the palmaris longus tendon: is reconstruction of the calcaneofibular ligament necessary? Foot Ankle Int. 1999;20:714-720. 24. Paterson R, Cohen B, Taylor D, Bourne A, Black J. Reconstruction of the lateral ligaments of the ankle using semi-tendinosis graft. Foot Ankle Int. 2000;21:413-419.
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Accelerated Versus Traditional Rehabilitation After Anterior Talofibular Ligament Reconstruction for Chronic Lateral Instability of the Ankle in Athletes Wataru Miyamoto, Masato Takao, Kazuaki Yamada and Takashi Matsushita Am J Sports Med 2014 42: 1441 originally published online April 10, 2014 DOI: 10.1177/0363546514527418 The online version of this article can be found at: http://ajs.sagepub.com/content/42/6/1441
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Accelerated Versus Traditional Rehabilitation After Anterior Talofibular Ligament Reconstruction for Chronic Lateral Instability of the Ankle in Athletes Wataru Miyamoto,*y MD, Masato Takao,y MD, Kazuaki Yamada,y MD, and Takashi Matsushita,y MD Investigation performed at Teikyo University School of Medicine, Tokyo, Japan Background: Although several reconstruction procedures for chronic lateral ankle instability using autografts have been reported, all have recommended postoperative immobilization and a nonweightbearing period. Hypothesis: Reconstructive surgery with a gracilis autograft using an interference fit anchoring system for chronic lateral ankle instability enables early accelerated rehabilitation and recovery with a return to activity without requiring immobilization. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 33 patients (33 feet) who underwent reconstruction of the anterior talofibular ligament with a gracilis autograft using interference screws were included; 15 were followed for 4 weeks with postoperative cast immobilization (group I), while 18 were followed with accelerated rehabilitation without immobilization (group A). Clinical and radiological results were evaluated based on the Karlsson and Peterson score, talar tilt angle, anterior displacement of the talus on stress radiography, and time between surgery and return to full athletic activity. Results: The mean Karlsson and Peterson scores before and 2 years after surgery were the following: for group I: 62.3 6 4.7 (range, 54-72) and 94.4 6 7.1 (range, 76-100), respectively (P \ .001), and for group A: 64.1 6 4.8 (range, 57-70) and 91.7 6 7.7 (range, 74100), respectively (P \ .001). The mean difference in the talar tilt angle compared with the contralateral side and mean displacement of the talus on stress radiography before and 2 years after surgery were the following: for group I: 8.7° 6 2.6° and 7.7 6 1.8 mm and 3.8° 6 1.5° and 4.0 6 1.6 mm, respectively, and for group A: 10.5° 6 3.4° and 8.7 6 2.1 mm and 4.3° 6 1.8° and 4.3 6 1.2 mm, respectively. Radiography revealed significantly improved postoperative outcomes in both groups (P \ .0001). No significant differences in the score and any parameters on stress radiography were evident at 2 years after surgery between the groups. The mean time between surgery and return to full athletic activity was significantly higher in group I (18.5 6 3.5 weeks) than in group A (13.4 6 2.2 weeks) (P \ .0001). No cases of reinjury were reported, and no differences in athletic performance ability were observed between the groups. Conclusion: Patients in group A returned to full athletic activity 5 weeks earlier than those in group I, demonstrating the advantage of accelerated rehabilitation after surgery. Keywords: ankle; lateral ligament; accelerated rehabilitation; reconstructive surgery
Several studies have shown that approximately 20% of patients with ankle inversion sprains did not achieve
good clinical outcomes even after adequate nonsurgical treatment and complained of persistent lateral ankle instability.6,12,26,27 Persistent pain, recurrent sprains, and repeated instances of the ankle giving way are hallmarks of chronic lateral instability of the ankle joint, and surgical treatment is indicated if such symptoms affect a person’s daily or sports activities.19 Although many types of surgical procedures for chronic lateral ankle instability exist, the majority of patients have been treated successfully by means of Brostro¨m-type anatomic repair, and only cases with insufficient remnants of the lateral ankle ligaments, which are not suitable for anatomic repair, need to undergo alternative reconstructive procedures. With regard to such alternative procedures, the recent trend is toward
*Address correspondence to Wataru Miyamoto, MD, Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan (e-mail: [email protected] kyo-u.ac.jp). y Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. The American Journal of Sports Medicine, Vol. 42, No. 6 DOI: 10.1177/0363546514527418 Ó 2014 The Author(s)
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anatomic reconstruction using autogenous grafts instead of tenodesis stabilization procedures, such as those of WatsonJones, Evans, and Christman-Snook.7,10,14,23,24,28,29 Recently, several autogenous grafts such as the semitendinosus tendon, gracilis tendon, plantaris tendon, toe extensor tendon, and bone–patellar tendon have been used for reconstruction of the lateral ligaments of the ankle joint, and these grafts are optimally fixed to the anatomic bone attachment points of the lateral ligaments by means of various fixation devices.1,7,10,14,23,24,28,29 In reconstructive surgery for chronic lateral ankle instability, all reported procedures using autografts involved a period of immobilization and nonweightbearing after surgery because these are time-honored procedures and the initial fixation strength of the autograft by fixation devices seems to be insufficient for early range of motion exercises or weightbearing.1,7,10,14,23,24,28,29 Since 2001, we have been performing anatomic reconstruction of the lateral ligaments of the ankle with a gracilis autograft using an interference fit anchoring system for chronic lateral ankle instability. Initially, cast immobilization of the operated ankle for 4 weeks and nonweightbearing activity for 2 weeks were used for the postoperative protocol. However, because recent biomechanical studies on interference screws have shown sufficient initial fixation strength of the bone-autograft attachment13,20 with respect to earlier rehabilitation, we hypothesized that reconstructive surgery with a gracilis autograft using an interference fit anchoring system enables early accelerated rehabilitation without immobilization of the operated ankle. Such an intervention has an obvious advantage, especially for sports athletes wishing to return to full athletic activity as early as possible. The purpose of this study was to investigate and compare clinical outcomes after reconstructive surgery with (1) the patient subjected to immobilization and delayed range of motion and weightbearing exercises and (2) the patient subjected to early accelerated rehabilitation without immobilization and also to evaluate the efficacy of early accelerated rehabilitation without immobilization for sports athletes with chronic lateral ankle instability.
MATERIALS AND METHODS Patients Between January 2007 and March 2010, a total of 69 athletes who experienced an inversion ankle sprain at least once during their sports activities and who had chronic ankle pain accompanied by a repetitive sense of the ankle giving way for more than 6 months visited our institution. On physical examination, all patients complained of pain when palpated at the anterior aspect of the lateral malleolus, and they also showed manual anterior drawer laxity. Talocrural instability was diagnosed by means of the varus stress test and the anterior drawer test of the talocrural joint using a Telos device (Telos SE 2000, Telos GmbH, Marburg, Germany) with a force of 50 N. A diagnosis of talocrural instability was made on detection of instability
with a talar tilt angle 5° compared with the contralateral side by the varus stress test and/or anterior talar displacement 6 mm by the anterior drawer test. In addition, stress radiography of the subtalar joint, reported by Yamamoto et al,32 was performed to evaluate the function of the calcaneofibular ligament (CFL). If the talocalcaneal angle was less than 10°, the subtalar joint was diagnosed as stable with an intact CFL. However, if a talocalcaneal angle of more than 10° was noted, the subtalar joint was diagnosed as unstable, indicating reconstruction of not only the anterior talofibular ligament (ATFL) but also the CFL. Furthermore, magnetic resonance imaging (MRI) was performed in all patients to evaluate complicated injuries including fractures, tendon injuries, and osteochondral lesions. Inclusion criteria were as follows: (1) talocrural instability on stress radiography of the talocrural joint, (2) stable subtalar joint on talocalcaneal stress radiography showing no need for CFL reconstruction,32 (3) no concomitant disorder confirmed on MRI, (4) no previous surgery on the affected lower extremity, (5) a healthy contralateral ankle, and (6) no response to nonoperative therapy for more than 3 months. Of the 69 patients, 33 (23 male and 10 female; 33 feet) patients who met the inclusion criteria were included. Institutional review board approval for this study and informed consent from all patients were obtained. Patients were divided into 2 groups after they approved the suggested procedure by filling out a special consent form. If the patient’s first examination at our institution occurred on an even-numbered day, the patient underwent reconstruction of the ATFL followed by postoperative cast immobilization of the operated ankle for 4 weeks (group I). If the first examination occurred on an odd-numbered day, the patient was treated by ATFL reconstruction with accelerated rehabilitation without postoperative immobilization (group A). Group I comprised 15 patients (10 male and 5 female; 15 feet) whose age at the time of surgery ranged from 18 to 43 years (mean, 27.7 6 8.1 years). Group A comprised 18 patients (13 male and 5 female; 18 feet) whose age at the time of surgery ranged from 21 to 40 years (mean, 26.4 6 5.2 years). Symptom duration ranged from 3 to 11 months (mean, 5.9 6 4.8 months) in group I and from 3 to 10 months (mean, 6.3 6 2.0 months) in group A. In each group, anatomic reconstruction of the ATFL was performed by applying an interference fit anchoring system with a gracilis autograft. No differences (major or subtle) in the surgical procedure were noted between the 2 groups.
Surgical Technique A gracilis tendon of the ipsilateral knee was harvested using a tendon harvester inserted through a medial knee skin incision of approximately 3 cm in length. A 9-cm segment of the harvested gracilis tendon was manufactured into an autograft and shaped into a useable form for reconstruction of the ATFL (Figure 1). Next, under a pneumotourniquet inflated to a pressure of approximately 300 mm Hg, a straight skin incision of approximately 3.5 cm in length was initiated at the tip of the distal fibula and continued in the anterior direction. The anterior border of the lateral malleolus was identified, and the ankle
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Figure 1. Gracilis tendon manufactured from an autograft harvested from the ipsilateral knee.
Figure 3. Overdrilling along the guide wire to create a bone tunnel to a depth of more than 20 mm with a cancellous bone–harvesting drill with a bit diameter of 6.5 mm.
Figure 2. Insertion of the guide wires through the fibular attachment and the talar attachment of the anterior talofibular ligament.
joint was opened both proximal and distal to the ATFL to prevent damage to the superficial peroneal nerve. After removal of the ATFL remnant, a guide wire was used to penetrate the fibula through the fibular attachment of the ATFL toward the proximal and posterior areas of the fibula, creating an angle of approximately 20° to the fibula’s axis. In addition, a guide wire was used to penetrate the talus through the talar attachment of the ATFL toward the distal posterior end of the medial malleolus (Figure 2). Along these guide wires, overdrilling was performed to create a bone tunnel to a depth of more than 20 mm using a cancellous bone–harvesting drill with a bit diameter of 6.5 mm (Meira Co Ltd, Nagoya, Japan). This drill, as its name implies, is used to harvest cylindrical cancellous bone during overdrilling (Figure 3). The ends of the
Figure 4. Insertion of each autograft end into the bone tunnel by means of a thread and pierced guide wire from the inside to the outside.
manufactured autograft were pulled through both bone tunnels from the inside to the outside by using a thread and pierced guide wire, such that the thread lay at the exit of each bone tunnel and passed through the skin (Figure 4). Then, each tunneled end of the autograft was fixed with a 5.0-mm interference screw (Tendon-Junction screw, Meira Co Ltd), with the ankle in the neutral position, using the pieces of cancellous bone that were cut from the harvested cancellous bone cylinder between the screw and each end of the autograft, and a load of approximately
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Figure 5. (A) Anatomic reconstruction of the anterior talofibular ligament (ATFL) using an interference fit anchoring system with a gracilis autograft. (B) Intraoperative photograph showing the implanted autograft. (C) Postoperative radiograph showing adequate positioning of each interference screw at the fibular and talar attachments of the ATFL. at 6 to 7 weeks after surgery in group I and at 2 to 3 weeks after surgery in group A. In both groups, patients were allowed to jog as soon as they achieved full weightbearing without pain, and if they could jog without pain, they were allowed to run. Return to training and finally full return to their preinjury sports activities were allowed when they experienced no difficulties in their sport-specific drills and when they were confident to return.
Evaluation
Figure 6. Postoperative rehabilitation program in group I with cast immobilization and in group A with accelerated rehabilitation without cast immobilization. ROM, range of motion. 30 N was manually applied to create tension in the autograft during screw fixation (Figure 5).
The clinical results of all patients were evaluated using the Karlsson and Peterson scoring system17 before surgery and at 2 years after surgery. Patients also underwent standard stress radiography of the talocrural joint at the same time to evaluate improvement in the talar tilt angle and anterior displacement of the talus, and results were compared with those obtained before surgery. In addition, the time between surgery and return to athletic activity, defined as a return to near preinjury performance levels, was investigated in each group.
Postoperative Management In group I, the operated ankle was immobilized with a short leg cast for 4 weeks, followed by application of a soft ankle orthosis for 4 weeks. Two weeks after surgery, weightbearing was allowed with the ankle cast on, and at 4 weeks after surgery, full weightbearing was allowed while wearing a soft ankle orthosis. Exercises to restore motion and strength conducted by a physical therapist began after cast removal. In group A, a soft ankle orthosis was applied immediately after surgery for 8 weeks, and weightbearing was allowed without restriction in accordance with the patient’s ability to endure. Exercises to restore motion and strength conducted by a physical therapist began 2 days after surgery. In both groups, all patients removed the soft ankle orthosis 8 weeks after surgery (Figure 6). Endurance training on a treadmill, sport-specific drills, and training to improve balance on a balance board began
Statistical Analysis Intraclass correlation coefficients (ICCs) were used to test the intraobserver and interobserver reliability of the radiological measurements, including the talar tilt angle and anterior displacement of the talus. Differences in the talar tilt angle compared with the contralateral side, displacement of the talus, and Karlsson and Peterson scores before surgery and at 2 years after surgery were assessed using the paired t test. Furthermore, differences in the talar tilt angle compared with the contralateral side, displacement of the talus, Karlsson and Peterson scores, and the time between surgery and return to full sports activities were assessed in both groups using the Mann-Whitney U test. P \ .05 was regarded as significant. All statistical analyses were performed with StatView software (version 5.0, Abacus Concepts, Berkeley, California, USA).
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TABLE 1 Treatment Outcomesa
Group I Karlsson and Peterson score Talar tilt angle compared with contralateral side, deg Anterior displacement of the talus, mm Group A Karlsson and Peterson score Talar tilt angle compared with contralateral side, deg Anterior displacement of the talus, mm
Before Surgery
2 Years After Surgery
P Value
62.3 6 4.7 (54-72) 8.7 6 2.6 (7-16) 7.7 6 1.8 (6-12)
94.4 6 7.1 (76-100) 3.8 6 1.5 (1-6) 4.0 6 1.6 (2-8)
\.0001 \.0001 \.0001
64.1 6 4.8 (57-70) 10.5 6 3.4 (6-15) 8.7 6 2.1 (6-13)
91.7 6 7.7 (74-100) 4.3 6 1.8 (2-6) 4.3 6 1.2 (3-7)
\.0001 \.0001 \.0001
a
Values are expressed as mean 6 standard deviation (range).
RESULTS
DISCUSSION
All patients were followed for 2 years. The mean Karlsson and Peterson scores of group I improved significantly from 62.3 6 4.7 (range, 54-72) before surgery to 94.4 6 7.1 (range, 76-100) at 2 years after surgery (P \ .0001). Similarly, the mean Karlsson and Peterson scores of group A improved significantly from 64.1 6 4.8 (range, 57-70) before surgery to 91.7 6 7.7 (range, 74-100) at 2 years after surgery (P \ .0001). There were no significant differences in the mean Karlsson and Peterson score at 2 years after surgery between the groups (P = .2523). The ICC for the intraobserver and interobserver reliability of the radiological measurement of the talar tilt angle was 0.987 and 0.987, respectively. Furthermore, the ICC for the intraobserver and interobserver reliability of the radiological measurement of anterior displacement of the talus was 0.955 and 0.972, respectively. In group I, the mean difference in the talar tilt angle compared with the contralateral side and mean anterior displacement of the talus on stress radiography were 8.7° 6 2.6° (range, 7°-16°) and 7.7 6 1.8 mm (range, 6-12 mm) before surgery and 3.8° 6 1.5° (range, 1°-6°) and 4.0 6 1.6 mm (range, 2-8 mm) at 2 years after surgery, respectively. In group A, the mean difference in the talar tilt angle and mean displacement of the talus on stress radiography were 10.5° 6 3.4° (range, 6°-15°) and 8.7 6 2.1 mm (range, 6-13 mm) before surgery and 4.3° 6 1.8° (range, 2°-6°) and 4.3 6 1.2 mm (range, 3-7 mm) at 2 years after surgery, respectively. The talar tilt angle and displacement of the talus were significantly improved after surgery in both groups (P \ .0001) (Table 1). There were no significant differences between the groups for the talar tilt angle (P = .1634) and displacement of the talus (P = .2318) at 2 years after surgery. All patients were able to return to their previous athletic activities, and the mean time between surgery and return to athletic activity was 18.5 6 3.5 weeks (range, 10-23 weeks) in group I and 13.4 6 2.2 weeks (range, 10-18 weeks) in group A, showing significant differences between the groups (P \ .0001). No surgical complications such as a superficial or deep infection, a nerve injury, or deep vein thrombosis were seen in any cases in either group. No cases of reinjury were reported, and no differences in performance ability were observed between the groups.
The gold standard for surgically treating chronic lateral instability of the ankle joint has been anatomic repair using remnants of the lateral ankle ligaments, and favorable long-term outcomes with good clinical prognosis have been reported after performing a modified Brostro¨m procedure.4,11,16 Furthermore, arthroscopic-assisted procedures that are less invasive than the conventional Brostro¨m procedure have been developed.9,21 However, for cases with insufficient remnants of the lateral ankle ligaments, which are not suitable for anatomic repair, anatomic reconstruction using autogenous grafts has been the main alternative procedure. Several reported reconstructive procedures have used autologous tendons such as the semitendinosus tendon, gracilis tendon, plantaris tendon, toe extensor tendon, and bone–patellar tendon as grafts for chronic lateral instability of the ankle joint.1,7,10,14,23,24,28,29 In these procedures, harvested autologous tendons are manufactured into autograft substitutes and fixed to both bone attachment points of the lateral ligaments by means of fixation devices.1,7,10,14,23,24,28,29 Several fixation devices and techniques such as a screw with a spiked washer, a bone suture anchor, an interference screw, and suturing are described in the literature, and all have good clinical outcomes.1,7,10,14,23,24,28,29 However, previously reported reconstructive procedures involving an autograft need a period of immobilization of the operated ankle joint as well as nonweightbearing activity on the lower extremity, and they never permit patients to perform accelerated postoperative range of motion exercises or early weightbearing activity.1,7,10,14,23,24,28,29 The most likely reason for this seems to be insufficient initial fixation strength for attaching the autograft to the bone attachment point with fixation devices for accelerated rehabilitation, although the initial fixation provided by different types of fixation devices has not been precisely investigated. On the other hand, previous studies have shown the undesired effects of joint immobilization on the ligament, capsule, musculature, periarticular bone, and articular cartilage.5,8,15,25 To avoid such effects, it is preferable to perform early accelerated joint motion and weightbearing without joint immobilization after joint surgery, and as
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expected, such rehabilitation after surgery seems to be most suitable after reconstructive surgery for chronic lateral ankle instability. The use of interference screws as an effective means of securing free grafts in bone tunnels has been widely advocated in anterior cruciate ligament reconstruction, and strong initial strength to fix free grafts in bone tunnels by means of interference screws with a large diameter has been reported by many investigators.18,30,31 Recently, because of the addition of a small-diameter version of the interference screw, clinical application of the interference screw has been further broadened to ligament reconstruction of the ankle, the patellofemoral joint, and the upper extremities, and subsequent mechanical analyses of small-diameter interference screw fixation strength have been reported.13,20 Jeys et al13 studied the biomechanical characteristics of a common bone suture anchor and a small interference screw with a diameter of 5.5 mm (Arthrex Inc, Naples, Florida, USA) by using a porcine bone and tendon model to represent ankle ligament reconstruction. In their study, the diameter of the created bone tunnel for fixation of the free graft by means of 5.5-mm interference screws was also 5.5 mm. Their study revealed that single pullto-failure testing of interference screws produces a mean load of 227 N, which was significantly greater than that of the bone suture anchors.13 Furthermore, Matsumoto et al20 studied the effect of the graft/bone tunnel crosssectional area ratio (GTR) to determine the initial fixation strength of small-diameter interference screws by using porcine knees and a patellar tendon. In their study, 2 bone tunnels with diameters of 4.5 or 5.0 mm were created, and a 4.0 mm–diameter interference screw was used.20 The results showed that the optimal GTR ranged from 60% to 90% and that the mean failure load was approximately 180 N for both bone tunnels if the host bone had a bone mineral density greater than 0.6 g/cm2.20 The initial fixation strengths of these small-diameter interference screws exceeded the mean load to failure of the ATFL, which is known from previous studies to be approximately 139 N.2,3 In the present study, the ipsilateral gracilis tendon was harvested as an autograft, and an interference screw with a diameter of 5.0 mm was used to fix the autograft to 5.5 mm–diameter bone tunnels, which were created at each bone attachment point of the ATFL. The gracilis tendon has sufficient tensile strength for reconstruction of the ATFL because the maximum failure load of the gracilis tendon is approximately 838 N.22 Furthermore, even if the harvested gracilis tendon is narrow and does not have a sufficient diameter to occupy 60% of the GTR, cancellous bone chips, which are inserted into the bone tunnel to protect the autograft from direct disruption by the screw and to develop an autograft–bone tunnel interface, can compensate for the occupation of the cross-sectional area. Of note, the cross-sectional area was insufficient in the gracilis autograft only, and all patients could achieve an optimal GTR after the autograft and placement of cancellous bone chips. Such a system enabled accelerated rehabilitation without immobilization after reconstructive surgery for chronic lateral ankle instability. In fact, patients in group A were able to return
to full sports activities significantly earlier (5 weeks) than those in group I and showed similar stability and clinical outcomes to those in group I at 2 years after surgery. This clearly demonstrates the disadvantage of immobilization and the advantage of accelerated rehabilitation after surgery. Accelerated rehabilitation is preferable if the initial fixation strength of the autograft is sufficiently confirmed. There are several limitations to this study. The sample population was small in both groups, and chronic lateral instability of the ankle joint due to injury of only the ATFL was evaluated. It is therefore necessary to evaluate the efficacy of the present procedure in a larger sample population undergoing accelerated rehabilitation. Moreover, evaluating long-term outcomes through follow-up is necessary to reveal the continuous effectiveness of the present procedure.
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