Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-3072-8
ANKLE
Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon Hyong Nyun Kim • June Young Jeon • Quanyu Dong • Kyu Cheol Noh • Kook Jin Chung • Hong Kyun Kim • Ji Hyo Hwang • Yong Wook Park
Received: 31 August 2013 / Accepted: 6 May 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The purpose of this study was to assess the results of a novel surgical technique for the treatment of chronic lateral ankle instability with attenuated or deficient ligamentous tissue that the modified Brostro¨m procedure could not be performed. A lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon has been performed. Methods Thirty-four consecutive patients treated with lateral ankle ligament reconstruction using anterior half of the peroneus longus tendon were enrolled. Median age at
Electronic supplementary material The online version of this article (doi:10.1007/s00167-014-3072-8) contains supplementary material, which is available to authorized users. H. N. Kim J. Y. Jeon Q. Dong K. C. Noh K. J. Chung H. K. Kim J. H. Hwang Y. W. Park (&) Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, College of Medicine, Hallym University, 948-1, Dalim-1dong, Youngdeungpo-gu, Seoul 150-950, South Korea e-mail: [email protected]; [email protected] H. N. Kim e-mail: [email protected]
surgery was 24 years (range 19–46 years). The clinical and radiologic outcomes were evaluated preoperatively and at a median of 21 months (range 12–51 months) follow-up. Results The Karlsson–Peterson ankle score significantly improved from 58.2 ± 10.9 points preoperatively to 83.9 ± 7.0 points at the last follow-up. Mechanical stability was achieved. The mean talar tilt angle significantly improved from 15.7° ± 3.5° preoperatively to 4.6° ± 1.7° at the last follow-up, and the mean anterior talar translation significantly improved from 7.3 ± 2.6 mm preoperatively to 4.1 ± 1.7 mm at the last follow-up. Fifteen patients (52 %) were very satisfied with the results, nine patients (31 %) were satisfied, four patients (14 %) were fair, and one patient (3 %) was dissatisfied with the results. Conclusions Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon can be a surgical option for chronic lateral ankle instability with attenuated or deficient ligaments. Level of evidence Case-series, Level IV. Keywords Chronic lateral ankle instability Chronic ligamentous insufficiency Lateral ankle ligament reconstruction Peroneus longus tendon Autograft
J. Y. Jeon e-mail: [email protected] Q. Dong e-mail: [email protected]
Introduction
K. C. Noh e-mail: [email protected]
Many techniques are available for the surgical reconstruction of chronic lateral ankle instability [2, 8, 12, 18, 24, 26]. Among them, the modified Brostro¨m procedure—the repair of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL)—has gained popularity [2, 15]. However, direct repair of the ligaments is often not an option when the local ligamentous tissue is severely attenuated or deficient [1, 3, 6, 11, 13, 14]. In such cases,
K. J. Chung e-mail: [email protected] H. K. Kim e-mail: [email protected] J. H. Hwang e-mail: [email protected]
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ankle ligaments can be replaced with local tendon grafts such as the peroneus brevis for non-anatomical reconstruction, or with distant grafts such as gracilis tendon, plantaris tendon, extensor digitorum longus tendon of the toe, or allograft tendon for reconstruction [1, 3, 6, 9, 11, 27]. Non-anatomical reconstruction with half or the entire peroneus brevis tendon is an invasive approach and has been reportedly associated with restriction of ankle and subtalar motion [19]. These non-anatomical reconstruction techniques are being increasingly replaced with anatomic reconstruction procedures that have the advantage of restoring normal mechanical restraints without serious restriction of the ankle or subtalar motion [11, 14]. The choice of graft tissue is known to have less influence on the clinical outcome than the type of reconstruction (anatomic versus non-anatomic). Thus, graft selection often depends more on the preference of the surgeon and less on graft considerations [21]. However, each graft and harvesting procedure has its own advantages and disadvantages [5]. The anterior half of the peroneus longus tendon has been reported to be an acceptable alternative autograft source with respect to its strength, safety, and donor site morbidity [31]. A study of 92 patients who underwent a variety of knee ligament reconstructions with the anterior half of the peroneus longus tendon autograft and were followed up for [2 years revealed no significant impairment of foot and ankle function [31]. In this study, we harvested the anterior half of the peroneus longus tendon by using a tendon stripper through one of the percutaneous incisions required for lateral ankle ligament reconstruction and used it as an autograft source for the reconstruction. Our hypothesis was that this technique would restore adequate lateral ankle stability for cases with severely attenuated or deficient lateral ankle ligaments, which are expected to have a poor outcome with direct ligament repair alone.
Materials and methods This study was performed on 34 consecutive patients (36 ankles) with chronic lateral ankle instability who underwent lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon by two of the authors from 2008 to 2011. Institutional review board approval was obtained. Patients provided informed consent and were then invited to a final follow-up office visit for a detailed evaluation. Five patients were not reachable; three of them had incorrect telephone numbers, and two declined to visit our clinic because they had moved to a distant location. The results of the operative procedures performed in the remaining 29 patients (31 ankles) are presented. There were 24 men and 5 women, and 2 patients with bilateral chronic lateral ankle
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instability underwent surgery for both ankles. Median age at surgery was 24 years (range, 19–46 years). Median follow-up duration was 21 months (range, 12–51 months). Before surgery, clinical, and radiologic examinations were performed to determine the presence of mechanical instability and concomitant pathologies. Ankle instability was demonstrated by stress radiography with a talar tilt angle 5° greater than that on the uninvolved side or an absolute value of[10° and anterior talar translation 5 mm greater than that on the uninvolved side or an absolute value of[9 mm [10, 23]. The indication for lateral ankle ligament reconstruction with the anterior half of the peroneus longus tendon was chronic lateral ankle instability with at least 6 months of unrelieved instability, and 3 months of failed rehabilitation, for which the Brostro¨m operation could not be performed because of insufficient local ligamentous tissue. The surgery was also performed for failed Brostro¨m operation cases, or those with a large ossicle within the lateral ligaments in which the removal of the ossicle resulted in a lack of remnant ligamentous tissue, which was expected to achieve poor outcome by direct ligament repair only. Patients with generalized ligamentous laxity and with severe ankle instability ([15° of talar tilt,[10 mm of anterior talar translation) were considered eligible for the surgery. Generalized ligamentous laxity was defined when the results of a minimum four of five tests were positive according to the Beighton and Horan scoring system [4]. Peroneal tendon tears were considered contraindications for harvesting the anterior half of the peroneus longus tendon. Before surgery, magnetic resonance imaging (MRI) was performed to evaluate any associated pathologies and ligament damage. If there were intra-articular pain or intra-articular pathologies, such as osteochondral lesions, ankle arthroscopy was performed at the time of lateral ankle reconstruction. Operative technique With the patient in a lateral decubitus position, a 4-cm curvilinear incision commonly used for the Brostro¨m procedure was made from the talar attachment of the ATFL to the distal tip of the lateral malleolus under tourniquet control. The ATFL and the CFL were examined. When ossicles were present within the ligaments, the ligaments were gently peeled off and the ossicles were removed. After evaluating for and confirming attenuation or deficiency of the ligamentous tissue, lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon was decided upon intra-operatively. Anterior half of the peroneus longus tendon harvesting technique A 1-cm longitudinal incision was made on the posterior margin of the lateral malleolus 3 cm proximal to the distal
Knee Surg Sports Traumatol Arthrosc Fig. 1 a A 1-cm longitudinal incision is made on the posterior c margin of the lateral malleolus 3 cm proximal to the distal tip and the peroneus longus tendon is pulled out of the incision. b The anterior half of the peroneus longus tendon is cut and split. A Krachow whip stitch is woven into the end of the anteriorly split tendon. c A 5-mmwide tendon stripper is introduced over the anterior half of the peroneus longus tendon and pushed in a proximal direction through the incision underneath the tendon sheath while pulling the tendon 7 cm proximal from the distal incision to keep the tendon under tension. Another incision is made 7 cm proximal from the second incision. Finally, the anterior half of the peroneus longus tendon is pulled out through the third incision and transected. An approximately 14-cm-long free tendon can be harvested for ankle reconstruction (Online Resource 1: technique video)
tip and just over the peroneal tendons. After dissection of the deep fascia, the peroneus longus tendon could be easily identified superficial to the peroneus brevis tendon. The peroneus longus tendon was then pulled out of the incision with a mosquito clamp (Fig. 1a) and the anterior half of the tendon (about 3.5–4.0 mm) was cut and split. A 2.0 Ethibond (Ethicon, Inc., Somerville, NJ, USA) suture was woven into the end of the anteriorly split tendon using a Krackow whip stitch (Fig. 1b). The route of the proximal portion of the tendon could be distinguished over the skin, and a second 1.5-cm transverse incision was made over the peroneus longus tendon 7 cm proximal from the initial incision. The proximal part of the peroneus longus tendon was pulled out through the second incision to keep the tendon under tension. Then, a 5-mm-wide tendon stripper was introduced over the 3.5 mm anterior portion of the peroneus longus tendon and pushed in a proximal direction through the incision underneath the tendon sheath (Fig. 1c). The anterior half of the peroneus longus tendon was pulled out through the second incision. A third 1.5 cm transverse incision was made over the peroneus longus tendon 7 cm proximal from the second incision. The tendon stripper was introduced again and pushed in a proximal direction. Finally, the anterior half of the peroneus longus tendon was pulled out through the third incision and transected. An approximately 14-cm-long free tendon could be harvested for lateral ankle ligament reconstruction (Online Resource 1: technique video). Lateral ankle ligament reconstruction technique After harvesting the anterior half of the peroneus longus tendon, lateral ankle reconstruction could be performed without changing the patient’s position. Lateral ankle ligament reconstruction was performed as described by Jung et al. [14]. A talar tunnel of 5-mm diameter and 20-mm depth was made on the anterior margin of the talar body at the ATFL attachment area. Two fibular tunnels were made at the footprint of the ATFL and CFL attachment. The
harvested anterior half of the peroneus longus tendon was passed through the proximal fibular tunnel, and the anterior end of the tendon was fixed into the talar tunnel at the ATFL attachment area with a 4.75-mm bioabsorbable interference screw (Arthrex Inc., Naples, FL, USA) to reconstruct the ATFL (Fig. 2). The tendon was sutured with the periosteum and the remnant tissue at the ATFL
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concentrate more on balance training and peroneal strengthening exercises. Clinical assessment
Fig. 2 Diagram showing lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon
footprint with the ankle in plantigrade neutral position. The remaining ATFL remnant was then laid over the graft and secured. The posterior end of the tendon was passed through the distal fibular tunnel. The tendon was then passed downward deep into the peroneal tendons. A 5-mm incision was made over the lateral calcaneal wall, and a 5.0-mm calcaneal tunnel was made. The tendon was inserted into the tunnel from lateral to medial and was tensioned with the ankle in plantigrade position and the subtalar joint in a neutral position. A 6.25-mm bioabsorbable interference screw (Arthrex) was then inserted from lateral to medial to reconstruct the CFL (Figs. 2, 3). All soft tissue layers were closed and the ankle was placed in a standard posterior splint. Post-operatively, the ankle was immobilized in a postoperative splint without weight bearing for 2 weeks, at which time the sutures were removed. Then, a short leg cast was applied in a neutral position for 2 weeks followed by soft ankle orthoses for another 4 weeks. Four weeks after surgery, active range of motion and partial weight bearing was allowed with a soft ankle orthosis. Gradually, full weight bearing was allowed. Balance training and proprioceptive exercises were encouraged. Before starting sports activities, when patients experienced ankle instability and a giving away sensation, they were advised to delay their sports activities and were encouraged to
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The Karlsson–Peterson ankle score was checked preoperatively and at final follow-up examination by an experienced physiotherapist blinded to the study details [16]. Patients were asked to rate their overall satisfaction with their surgical results as ‘‘very satisfied’’, ‘‘satisfied’’, ‘‘fair’’, or ‘‘dissatisfied’’. Radiographically, the anterior talar translation and the talar tilt angle were measured on the stress radiographs preoperatively and at final follow-up examination. Square-hop and side-hop tests were performed preoperatively and at final follow-up examination for 22 patients operated upon at one orthopaedic centre. At the final follow-up examination, the two tests were performed on the operated limb and on the contralateral uninjured limb, and results were compared to check for the peroneus longus function after anterior half of the peroneus longus tendon harvest (Online Resource 2, 3). For the square-hop test, a 40 9 40-cm square was marked on the floor with tape. Starting outside of the square, participants were instructed to hop on one limb in and out of the square, as fast as possible for five repetitions. One repetition constituted hopping in and out of the tape outline completely around the square back to the starting point. Before testing initiation, the test was demonstrated along with verbal instructions. To familiarize themselves with the protocol, patients performed one trial before the test. The time taken to complete the test was recorded using
Fig. 3 Intraoperative picture shows insertion of a bioabsorbable interference screw into the calcaneal tunnel with the posterior end of the anterior half of the peroneus longus tendon to reconstruct the CFL. Minimal incisions are enough for the autograft tendon harvest and the lateral ankle reconstruction
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a hand-held stopwatch to the nearest 0.01 s. The outcome measure was averaged over two trials. For the side-hop test, patients were instructed to hop on one limb laterally over a 30-cm distance. One repetition constituted hopping laterally to the 30 cm point and then back to the starting location. Each patient completed ten repetitions and was instructed to do so as quickly as possible. The outcome measure was averaged over two trials. The Korean Armed Forces Medical Command IRB (AFMC-13-IRB-009) approved the current study. Statistical analysis Statistical analysis was performed using SPSS version 12.0 (SPSS, SPSS Inc., Chicago, IL, USA) software. Data normality was assessed by the Kolmogorov–Smirnov test. The paired t test and Wilcoxon’s signed-rank test were used to compare preoperative and post-operative values (Karlsson– Peterson ankle score, and radiologic measurements). Statistical significance was accepted for p values \0.05.
Results The clinical and radiologic results are presented in Table 1. Fifteen patients (52 %) were very satisfied with the results, nine patients (31 %) were satisfied, four patients (14 %) were fair, and one patient (3 %) was dissatisfied with the results. One patient who was dissatisfied with the result had osteochondral lesion of the talus treated with arthroscopic microfracture at the time of lateral ankle reconstruction and still had deep ankle pain in the area of the osteochondral lesion. Four patients who gave a ‘‘fair’’ rating for the result did not return to their previous level of sports activity. However, all of them achieved mechanical stability on ankle stress radiographs. Seven patients noted developing ankle sprain after the operation. However, none of the patients required reoperation. Five of these injuries were mild sprains that did not require medication or Table 1 Clinical and radiologic results
Karlsson–Peterson ankle score (points)
Preoperative
Postoperative
p value
58.2 ± 10.9
83.9 ± 7.0
p \ 0.001
Stress radiograph Talar tilt angle (°) Anterior displacement (mm)
15.7 ± 3.5
4.6 ± 1.7
p \ 0.001
7.3 ± 2.6
4.1 ± 1.7
p \ 0.001
19.0 ± 2.0 11.5 ± 1.2
17.2 ± 1.1 10.3 ± 0.8
p \ 0.001 p \ 0.001
Functional performance test Square-hop test (s) Side-hop test (s)
immobilization. Five patients had tenderness on the bioabsorbable screw insertion site on the calcaneus when pressed, but this did not disturb activities. Four patients developed post-operative anterolateral ankle pain that lasted [6 months; however, in three of them, the pain subsided within 12 months. No patient complained of discomfort around the tendon harvest area during activities. None of the patients were suspected to have peroneus longus rupture. Twelve patients underwent ankle arthroscopy. Two patients had osteochondral lesions on the medial talus and were operated upon with microfracture bone marrow stimulation; three patients had os trigonum syndrome causing posterior impingement that was treated with posterior ankle arthroscopy; eight patients had anterolateral soft tissue impingement; and ten patients had synovitis. Two patients had anterior bony impingement treated with ankle arthroscopy and miniarthrotomy for resection of the bony spurs. At the last follow-up examination, square-hop and sidehop tests were performed on both the tendon harvested limb and the contralateral uninjured limb, and results were compared to check for the peroneus longus function after the anterior half of the peroneus longus tendon harvest. No significant difference was observed in the square-hop test (n.s.) between the tendon harvested limb (17.2 ± 1.1 s) and the contralateral limb (16.9 ± 1.6 s). Similarly no significant difference was observed in the side-hop test (n.s.) between the tendon harvested limb (10.3 ± 0.8 s) and the contralateral limb (10.2 ± 0.8 s).
Discussion The most important findings of the present study was that lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon showed significant improvements in Karlsson–Peterson ankle score and achieved mechanical stability without significant complications. The anterior half of the peroneus longus tendon could be easily harvested through one of the percutaneous incisions required for ankle reconstruction without the need for patient repositioning. Lateral ankle reconstruction could be accomplished through a small curvilinear incision similar to the incision for the Brostro¨m procedure with the addition of two percutaneous incisions. Lateral ankle ligament reconstruction using an allograft or autograft tendon is recommended for patients with chronic lateral ankle instability with severely attenuated or deficient lateral ankle ligaments, which are expected to have a poor outcome with direct ligament repair alone [1, 11, 14] Although the modified Brostro¨m procedure is widely used for the surgical treatment of chronic lateral
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ankle instability, contraindications have now been suggested after further experience with this direct ligament repair, including failed previous reconstructive surgery, the presence of long-standing ankle instability, generalized ligamentous laxity or increased size or weight [1, 11, 14]. Remnants of the ruptured ligaments degenerate over time and are therefore sometimes inadequate for use as reconstructive material because of both their low tensile force and shortening with respect to normal length [23]. When a large ossicle is present within the lateral ligaments, removal of the ossicle can result in a lack of remnant ligamentous tissue and leave a gap within the ATFL and CFL that may not be approximated [18]. These conditions can be the indications for lateral ankle ligament reconstruction augmented by an allograft or autograft tendon. Many techniques of lateral ankle ligament reconstruction with various autograft tendons or allograft tendon have reportedly shown satisfactory results [1, 11, 28]. However, we believe our technique has several important advantages worth mentioning. First, the small curvilinear incision used in our technique is small compared with the incisions used in other reconstruction techniques and is similar to the incision for the Brostro¨m procedure. Minimal incision results in less post-operative swelling and pain [30]. Our technique enables the use of the small curvilinear incision for the Brostro¨m procedure and when attenuated or deficient lateral ligaments are found intraoperatively, conversion to reconstruction is straightforward with the addition of two percutaneous incisions. Second, the anterior half of the peroneus longus tendon can be easily harvested and used for the reconstruction since the peroneus longus tendon is superficial in the distal leg and has no juncturae and adherence to the surrounding soft tissue. Furthermore, harvest of the anterior half of the peroneus longus tendon can be achieved through one of the percutaneous incisions for the lateral ankle reconstruction without changing the patient’s position. Therefore, in an unexpected condition such as inadequate lateral ligaments for repair being found intraoperatively, without the allograft being prepared at the time of operation, anterior half of the peroneus longus tendon can be easily harvested and used for the reconstruction. One of the widely used autograft sources for the ankle reconstruction is the gracilis tendon [6, 11, 28]. The gracilis tendon provides an excellent graft source for reconstruction as the usable length of this tendon is [20 cm, which is enough to reconstruct both the ATFL and CFL. The strength and the diameter of the tendon are suitable for reconstruction without the need to weave the tendon several times, as is needed for tendons with a smaller diameter such as the plantaris or extensor digitorum longus tendons. Minimum donor site morbidity has been reported when the gracilis tendon is harvested for
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anterior cruciate ligament (ACL) reconstruction. However, to harvest a gracilis tendon when reconstruction is decided intraoperatively after the inspection of the lateral ligaments, the patient’s position has to be changed from a semilateral or lateral position to a supine position for the harvest, and then back to the semilateral or lateral position for the reconstruction. With our technique of using the anterior half of the peroneus longus tendon, this position change is not necessary. When the surgeon is not familiar with the local anatomy around the knee, inadvertent saphenous nerve injury during the harvesting procedures may result in numbness around the harvest site, and precutting of the tendon may occur when detaching the juncturae connected to the tendon. The plantaris or extensor digitorum longus tendon can be used [1, 3, 21, 27]; however, the plantaris tendon can be absent in up to 19 % of cases [1]. The extensor digitorum longus tendon is sometimes difficult to harvest owing to juncturae and its adherence to the surrounding soft tissue. The resultant postoperative weakness of the toe extension can be a disadvantage [1]. The use of an allograft tendon allows a shorter operation time and prevents donor site morbidity. However, it raises issues of possible disease transmission and high cost. Exogenous material bears the risks of hypersensitivity, local inflammation, or infection. It is sometimes not a reliable alternative given the relative shortage of such grafts [14]. The anterior half of the peroneus longus tendon has been reported to be an acceptable alternative for autograft use with respect to its strength, safety, and donor site morbidity. The strength of the anterior half of the peroneus longus tendon is greater than that of the gracilis tendon. In a cadaveric study, the failure load of the anterior half of the peroneus longus tendon accounted for 97.69 and 147.94 % of the semitendinosus and gracilis tendons, respectively [30]. A study of 92 patients who underwent a variety of knee ligament reconstructions with the anterior half of the peroneus longus tendon autograft and followed up for [2 years revealed that there was no significant impairment of the foot and ankle function after the harvest of the anterior half of the peroneus longus tendon. The clinical study showed that the preoperative and post-operative American Orthopedic Foot and Ankle Society scores were 97.4 ± 2.0 and 97.2 ± 1.6 (n.s.), respectively, whereas the preoperative and post-operative Foot and Ankle Disability Index scores were 96.8 ± 2.2 and 96.9 ± 2.5 (n.s.), respectively. No signs of peroneal nerve injury, peroneus longus tendon rupture, or tendinopathy were found [31]. There are disadvantages to using anterior half of the peroneus longus tendon for lateral ankle reconstruction. Disturbing one of the evertor and dynamic lateral ankle stabilizer can have drawbacks. However, we believe lateral ankle ligament reconstruction with the anterior half of the
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peroneus longus tendon is a better option than using the peroneus brevis tendon for non-anatomical reconstruction, since the peroneus brevis is a more effective evertor than the peroneus longus [7, 17]. Peroneus brevis is the primary dynamic stabilizer of the ankle joint and should therefore remain intact and undisturbed whenever possible [17]. Although the peroneus longus tendon is one of the dynamic lateral ankle stabilizers, the clinical results of using split peroneus longus tendon for lateral ankle reconstruction have been satisfactory [7, 17]. One study of 25 consecutive patients who underwent autologous split peroneus longus lateral ankle stabilization reported that 92 % demonstrated good to excellent outcomes in a mean follow-up period 29.5 months [7]. The posterior limb of the split peroneus longus tendon was rerouted through an osseous tunnel to reconstruct the lateral ligaments. Kennedy et al. [17] harvested a 4.5-cm-long and 4-mm-thick band of the peroneus longus tendon from around the posteroinferior corner of the lateral malleolus and reconstructed the ATFL for 57 patients with chronic lateral ankle instability. At a mean follow-up period of 32 months, the Foot and Ankle Outcome Score improved from 58 points to 89 points and the Short Form-12 score from 48 to 80 points. The results of the current study in a series of 31 ankles are encouraging, with 24 of 29 (83 %) patients being very satisfied or satisfied with the results of using anterior half of the peroneus longus tendon for reconstruction. The Karlsson-Peterson ankle score significantly improved by a mean 25.6 ± 12.8 points (p \ 0.001). Mechanical stability was achieved. Functional performance significantly improved for squarehop test and for side-hop test. The stability of the ankle joint is commonly assessed by the anterior drawer test or the varus stress test. Although these tests are useful for assessing ankle joint instability caused by a ligament tear, they are unable to evaluate the degree of joint instability during dynamic activity, which is controlled not only by static factors such as the ligaments but also by dynamic factors such as muscle strength, reaction time, or stiffness. Square-hop test and side-hop test were performed preoperatively and at final follow-up examination to check for the dynamic factors. Functional performance tests including the square-hop test and the side-hop test consist of jumping, landing, and cutting activities that produce a high load on the joints of the lower leg. Many studies have reported that these tests can be used to determine the presence of functional ankle instability [8, 25, 29]. In a study of 62 athletes (31 with functional ankle instability, 31 without functional ankle instability), significant performance differences were found between subjects with functional ankle instability and healthy subjects in the square-hop test and side-hop test. The test–retest reliability determined by intraclass correlation coefficient was 0.90 for the square-hop test and 0.84
for the side-hop test [25]. Furthermore, in the current study, the two tests were performed on the anterior half of the peroneus longus tendon harvested limb and on the contralateral uninjured limb at the final follow-up examination and were compared to check if the anterior half of the peroneus longus tendon harvest led to impairment of peroneus longus function to a degree causing functional impairment of ankle stability. No significant difference was observed between the anterior half of the peroneus longus tendon harvested limb and the non-harvested limb in the square-hop test (n.s.) and the side-hop test (n.s.) at the last follow-up examination. Therefore, functional performance could have not been impaired after anterior half of the peroneus longus tendon harvest or recovered at the last follow-up examination. Yoshida et al. [29] evaluated muscle activity during the side-hop test using electromyography. The peroneus longus was activated at approximately 120–160 % of the maximal voluntary contraction (the maximal voluntary contraction of the peroneus longus was measured with the subject in a sitting position with the foot plantar flexed to 10°–20° and then everted) during the contact phase and 50–80 % of the maximal voluntary contraction during the flight phase of the side-hop test which reveals that peroneus longus is largely involved during the test and that peroneus longus activity is largely required to perform the test. A study of 92 patients who underwent a variety of knee ligament reconstructions with the anterior half of the peroneus longus tendon autograft and were followed up for [2 years revealed that no significant impairment of the foot and ankle function was observed after the harvest of the anterior half of the peroneus longus tendon, and only one patient had an ankle sprain 15 months after surgery with no clear association found between this ankle sprain and the previous anterior half of the peroneus longus tendon harvest [31]. However, we acknowledge that the two functional performance tests performed in the current study cannot evaluate the function of peroneus longus alone after anterior half of the peroneus longus tendon harvest and that there is no existing method to check the function of the peroneus longus alone [20]. Another limitation of the current study is that seven patients in the study had bilateral ankle instability and this could be a confounding variable not controlled in the study. These patients could have shown better functional performance on their anterior half of the peroneus longus tendon harvested limb compared with the contralateral limb with ankle instability. The small number of subjects is another limitation of this study. Another disadvantage of using the anterior half of the peroneus longus tendon for reconstruction is that it may not be adequate to use the anterior half of the peroneus longus tendon when there are splits or tears in the peroneus longus tendon. When these pathologies were suspected from
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physical examination and MRI results, we did not harvest the anterior half of the peroneus longus tendon because of the risk of tendon rupture. However, none of these pathologies have been previously reported after anterior half of the peroneus longus tendon harvest for ACL reconstruction or split peroneus longus tendon lateral ankle stabilization. In the current study, none of these pathologies were suspected after the harvest at the final follow-up examination. Peterson et al. [22] reported that the peroneus longus tendon has two avascular zones, one located in the region where the tendon turns around the lateral malleolus and the other located where the tendon turns around the cuboid. These are the common sites of tendon rupture and tenosynovitis occurrences. With our technique of harvesting the anterior half of the peroneus longus tendon from 3 cm proximal from the distal tip of the lateral malleolus, the portion of the tendon that turns around the lateral malleolus is kept intact and the posterior portion where the blood supply enters remains undisturbed. Therefore, post-operative tendon rupture or tenosynovitis are less likely to develop with our technique compared with the other peroneus longus tendon harvesting techniques, such as that from the posterior portion of the peroneus longus tendon around the posteroinferior corner of the lateral malleolus, or split peroneus longus lateral ankle stabilization using the posterior limb of the peroneus longus tendon for the reconstruction [7, 17]. This study is limited by its retrospective, non-comparative nature. Furthermore, this study is limited by the small number of subjects and the short follow-up period. However, the results of the current procedures in a series of 31 ankles are encouraging. The facts that the anterior half of the peroneus longus tendon can be harvested easily through the incision for lateral ligament reconstruction without the need for repositioning is a considerable advantage of this technique. Although we cannot recommend the current surgical procedure as a preferred method for chronic lateral ankle instability without a prospective comparative study, we believe that using the anterior half of the peroneus longus tendon for lateral ankle reconstruction is a better option than using the peroneus brevis tendon for nonanatomic reconstruction. In an unexpected condition such as inadequate lateral ligaments for Brostro¨m repair being found intraoperatively, without the allograft being prepared at the time of operation, anterior half of the peroneus longus tendon can be easily harvested and used for the reconstruction.
Conclusion Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon can be a surgical option for chronic ankle instability with attenuated or deficient
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ligaments that the modified Brostro¨m procedure cannot be performed.
References 1. Ahn JH, Choy W, Kim H (2011) Reconstruction of the lateral ankle ligament with a long extensor tendon graft of the fourth toe. Am J Sports Med 39(3):637–644 2. Ajis A, Younger AS, Maffulli N (2006) Anatomic repair for chronic lateral ankle instability. Foot Ankle Clin 11(3):539–545 3. Anderson ME (1985) Reconstruction of the lateral ligaments of the ankle using the plantaris tendon. J Bone Joint Surg Am 67(6):930–934 4. Beighton P, Horan F (1969) Orthropaedic aspects of the EhlersDanlos syndrome. J Bone Joint Surg Br 51:444–453 5. Bohnsack M, Su¨rie B, Kirsch L, Wu¨lker N (2002) Biomechanical properties of commonly used autogenous transplants in the surgical treatment of chronic lateral ankle instability. Foot Ankle Int 23(7):661–664 6. Boyer DS, Younger AS (2006) Anatomic reconstruction of the lateral ligament complex of the ankle using a gracilis autograft. Foot Ankle Clin 11(3):585–595 7. Budny AM, Schuberth JM (2012) Autologous split peroneus longus lateral ankle stabilization. J Foot Ankle Surg 51(5):588–592 8. Caffrey E, Docherty CL, Schrader J, Klossner J (2009) The ability of 4 single-limb hopping tests to detect functional performance deficits in individuals with functional ankle instability. J Orthop Sports Phys Ther 39(11):799–806 9. Caprio A, Oliva F, Treia F, Maffullin N (2006) Reconstruction of the lateral ankle ligaments with allograft in patients with chronic ankle instability. Foot Ankle Clin 11(3):597–605, 2007:1455–1458 10. Colville MR (1998) Surgical treatment of the unstable ankle. J Am Acad Orthop Surg 6(6):368–377 11. Coughlin MJ, Schenck RC, Grebing BR, Treme G (2004) Comprehensive reconstruction of the lateral ankle for chronic instability using a free gracilis graft. Foot Ankle Int 25(4):231–241 12. Espinosa N, Smerek J, Kadakia AR, Myerson MS (2006) Operative management of ankle instability: reconstruction with open and percutaneous methods. Foot Ankle Clin 11(3):547–565 13. Ibrahim SA, Hamido F, Al Misfer AK, Ghafar SA, Awad A, Salem HKh, Alhran H, Khirait S (2011) Anatomical reconstruction of the lateral ligaments using Gracilis tendon in chronic ankle instability; a new technique. Foot Ankle Surg 17(4):239–246 14. Jung HG, Kim TH, Park JY, Bae EJ (2012) Reconstruction of the anterior talofibular and calcaneofibular ligaments using a semitendinosus tendon allograft and interference screws. Knee Surg Sports Traumatol Arthrosc 20(8):1432–1437 15. Karlsson J, Eriksson BI, Bergsten T, Rudholm O, Swa¨rd L (1997) Comparison of two reconstructions for chronic lateral instability of the ankle joint. Am J Sports Med 25(1):48–53 16. Karlsson J, Peterson L (1991) Evaluation of ankle joint function: the use of a scoring scale. The Foot 1(1):15–19 17. Kennedy JG, Smyth NA, Fansa AM, Murawski CD (2012) Anatomic lateral ligament reconstruction in the ankle: a hybrid technique in the athletic population. Am J Sports Med 40(10):2309–2317 18. Kim BS, Choi WJ, Kim YS, Lee JW (2010) The effect of an ossicle of the lateral malleolus on ligament reconstruction of chronic lateral ankle instability. Foot Ankle Int 31(3):191–196
Knee Surg Sports Traumatol Arthrosc 19. Krips R, van Dijk CN, Halasi T, Lehtonen H, Moyen B, Lanzetta A, Farkas T, Karlsson J (2000) Anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a 2- to 10-year follow-up, multicenter study. Knee Surg Sports Traumatol Arthrosc 8(3):173–179 20. Lo¨fvenberg R, Ka¨rrholm J, Sundelin G, Ahlgren O (1995) Prolonged reaction time in patients with chronic lateral instability of the ankle. Am J Sports Med 23(4):414–417 21. Pagenstert GI, Hintermann B, Knupp M (2006) Operative management of chronic ankle instability: plantaris graft. Foot Ankle Clin 11(3):567–583 22. Petersen W, Bobka T, Stein V, Tillmann B (2000) Blood supply of the peroneal tendons: injection and immunohistochemical studies of cadaver tendons. Acta Orthop Scand 71(2):168–174 23. Sammarco GJ, Idusuyi OB (1999) Reconstruction of the lateral ankle ligaments using a split peroneus brevis tendon graft. Foot Ankle Int 20(2):97–103 24. Sekir U, Yildiz Y, Hazneci B, Ors F, Saka T, Aydin T (2008) Reliability of a functional test battery evaluating functionality, proprioception, and strength in recreational athletes with functional ankle instability. Eur J Phys Rehabil Med 44(4):407–415 25. Sharma N, Sharma A, Sandhu J (2011) Functional performance testing in athletes with functional ankle instability. Asian J Sports Med 2(4):249–258
26. Snook GA (1985) Long-term results of the Chrisman-Snook operation for reconstruction of the lateral ligaments of the ankle. J Bone Joint Surg Am 67(1):1–7 27. Takahashi T, Nakahira M, Kaho K, Kawakami T (2003) Anatomical reconstruction of chronic lateral ligament injury of the ankle using pedicle tendon of the extensor digitorum longus. Arch Orthop Trauma Surg 123(4):175–179 28. Takao M, Oae K, Uchio Y, Ochi M, Yamamoto H (2005) Anatomical reconstruction of the lateral ligaments of the ankle with a gracilis autograft: a new technique using an interference fit anchoring system. Am J Sports Med 33(6):814–823 29. Yoshida M, Taniguchi K, Katayose M (2011) Analysis of muscle activity and ankle joint movement during the side-hop test. J Strength Cond Res 25(8):2255–2264 30. Youn H, Kim YS, Lee J, Choi WJ, Lee JW (2012) Percutaneous lateral ligament reconstruction with allograft for chronic lateral ankle instability. Foot Ankle Int 33(2):99–104 31. Zhao J, Huangfu X (2012) The biomechanical and clinical application of using the anterior half of the peroneus longus tendon as an autograft source. Am J Sports Med 40(3):662–671
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ANKLE
Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon Hyong Nyun Kim • June Young Jeon • Quanyu Dong • Kyu Cheol Noh • Kook Jin Chung • Hong Kyun Kim • Ji Hyo Hwang • Yong Wook Park
Received: 31 August 2013 / Accepted: 6 May 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The purpose of this study was to assess the results of a novel surgical technique for the treatment of chronic lateral ankle instability with attenuated or deficient ligamentous tissue that the modified Brostro¨m procedure could not be performed. A lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon has been performed. Methods Thirty-four consecutive patients treated with lateral ankle ligament reconstruction using anterior half of the peroneus longus tendon were enrolled. Median age at
Electronic supplementary material The online version of this article (doi:10.1007/s00167-014-3072-8) contains supplementary material, which is available to authorized users. H. N. Kim J. Y. Jeon Q. Dong K. C. Noh K. J. Chung H. K. Kim J. H. Hwang Y. W. Park (&) Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, College of Medicine, Hallym University, 948-1, Dalim-1dong, Youngdeungpo-gu, Seoul 150-950, South Korea e-mail: [email protected]; [email protected] H. N. Kim e-mail: [email protected]
surgery was 24 years (range 19–46 years). The clinical and radiologic outcomes were evaluated preoperatively and at a median of 21 months (range 12–51 months) follow-up. Results The Karlsson–Peterson ankle score significantly improved from 58.2 ± 10.9 points preoperatively to 83.9 ± 7.0 points at the last follow-up. Mechanical stability was achieved. The mean talar tilt angle significantly improved from 15.7° ± 3.5° preoperatively to 4.6° ± 1.7° at the last follow-up, and the mean anterior talar translation significantly improved from 7.3 ± 2.6 mm preoperatively to 4.1 ± 1.7 mm at the last follow-up. Fifteen patients (52 %) were very satisfied with the results, nine patients (31 %) were satisfied, four patients (14 %) were fair, and one patient (3 %) was dissatisfied with the results. Conclusions Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon can be a surgical option for chronic lateral ankle instability with attenuated or deficient ligaments. Level of evidence Case-series, Level IV. Keywords Chronic lateral ankle instability Chronic ligamentous insufficiency Lateral ankle ligament reconstruction Peroneus longus tendon Autograft
J. Y. Jeon e-mail: [email protected] Q. Dong e-mail: [email protected]
Introduction
K. C. Noh e-mail: [email protected]
Many techniques are available for the surgical reconstruction of chronic lateral ankle instability [2, 8, 12, 18, 24, 26]. Among them, the modified Brostro¨m procedure—the repair of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL)—has gained popularity [2, 15]. However, direct repair of the ligaments is often not an option when the local ligamentous tissue is severely attenuated or deficient [1, 3, 6, 11, 13, 14]. In such cases,
K. J. Chung e-mail: [email protected] H. K. Kim e-mail: [email protected] J. H. Hwang e-mail: [email protected]
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ankle ligaments can be replaced with local tendon grafts such as the peroneus brevis for non-anatomical reconstruction, or with distant grafts such as gracilis tendon, plantaris tendon, extensor digitorum longus tendon of the toe, or allograft tendon for reconstruction [1, 3, 6, 9, 11, 27]. Non-anatomical reconstruction with half or the entire peroneus brevis tendon is an invasive approach and has been reportedly associated with restriction of ankle and subtalar motion [19]. These non-anatomical reconstruction techniques are being increasingly replaced with anatomic reconstruction procedures that have the advantage of restoring normal mechanical restraints without serious restriction of the ankle or subtalar motion [11, 14]. The choice of graft tissue is known to have less influence on the clinical outcome than the type of reconstruction (anatomic versus non-anatomic). Thus, graft selection often depends more on the preference of the surgeon and less on graft considerations [21]. However, each graft and harvesting procedure has its own advantages and disadvantages [5]. The anterior half of the peroneus longus tendon has been reported to be an acceptable alternative autograft source with respect to its strength, safety, and donor site morbidity [31]. A study of 92 patients who underwent a variety of knee ligament reconstructions with the anterior half of the peroneus longus tendon autograft and were followed up for [2 years revealed no significant impairment of foot and ankle function [31]. In this study, we harvested the anterior half of the peroneus longus tendon by using a tendon stripper through one of the percutaneous incisions required for lateral ankle ligament reconstruction and used it as an autograft source for the reconstruction. Our hypothesis was that this technique would restore adequate lateral ankle stability for cases with severely attenuated or deficient lateral ankle ligaments, which are expected to have a poor outcome with direct ligament repair alone.
Materials and methods This study was performed on 34 consecutive patients (36 ankles) with chronic lateral ankle instability who underwent lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon by two of the authors from 2008 to 2011. Institutional review board approval was obtained. Patients provided informed consent and were then invited to a final follow-up office visit for a detailed evaluation. Five patients were not reachable; three of them had incorrect telephone numbers, and two declined to visit our clinic because they had moved to a distant location. The results of the operative procedures performed in the remaining 29 patients (31 ankles) are presented. There were 24 men and 5 women, and 2 patients with bilateral chronic lateral ankle
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instability underwent surgery for both ankles. Median age at surgery was 24 years (range, 19–46 years). Median follow-up duration was 21 months (range, 12–51 months). Before surgery, clinical, and radiologic examinations were performed to determine the presence of mechanical instability and concomitant pathologies. Ankle instability was demonstrated by stress radiography with a talar tilt angle 5° greater than that on the uninvolved side or an absolute value of[10° and anterior talar translation 5 mm greater than that on the uninvolved side or an absolute value of[9 mm [10, 23]. The indication for lateral ankle ligament reconstruction with the anterior half of the peroneus longus tendon was chronic lateral ankle instability with at least 6 months of unrelieved instability, and 3 months of failed rehabilitation, for which the Brostro¨m operation could not be performed because of insufficient local ligamentous tissue. The surgery was also performed for failed Brostro¨m operation cases, or those with a large ossicle within the lateral ligaments in which the removal of the ossicle resulted in a lack of remnant ligamentous tissue, which was expected to achieve poor outcome by direct ligament repair only. Patients with generalized ligamentous laxity and with severe ankle instability ([15° of talar tilt,[10 mm of anterior talar translation) were considered eligible for the surgery. Generalized ligamentous laxity was defined when the results of a minimum four of five tests were positive according to the Beighton and Horan scoring system [4]. Peroneal tendon tears were considered contraindications for harvesting the anterior half of the peroneus longus tendon. Before surgery, magnetic resonance imaging (MRI) was performed to evaluate any associated pathologies and ligament damage. If there were intra-articular pain or intra-articular pathologies, such as osteochondral lesions, ankle arthroscopy was performed at the time of lateral ankle reconstruction. Operative technique With the patient in a lateral decubitus position, a 4-cm curvilinear incision commonly used for the Brostro¨m procedure was made from the talar attachment of the ATFL to the distal tip of the lateral malleolus under tourniquet control. The ATFL and the CFL were examined. When ossicles were present within the ligaments, the ligaments were gently peeled off and the ossicles were removed. After evaluating for and confirming attenuation or deficiency of the ligamentous tissue, lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon was decided upon intra-operatively. Anterior half of the peroneus longus tendon harvesting technique A 1-cm longitudinal incision was made on the posterior margin of the lateral malleolus 3 cm proximal to the distal
Knee Surg Sports Traumatol Arthrosc Fig. 1 a A 1-cm longitudinal incision is made on the posterior c margin of the lateral malleolus 3 cm proximal to the distal tip and the peroneus longus tendon is pulled out of the incision. b The anterior half of the peroneus longus tendon is cut and split. A Krachow whip stitch is woven into the end of the anteriorly split tendon. c A 5-mmwide tendon stripper is introduced over the anterior half of the peroneus longus tendon and pushed in a proximal direction through the incision underneath the tendon sheath while pulling the tendon 7 cm proximal from the distal incision to keep the tendon under tension. Another incision is made 7 cm proximal from the second incision. Finally, the anterior half of the peroneus longus tendon is pulled out through the third incision and transected. An approximately 14-cm-long free tendon can be harvested for ankle reconstruction (Online Resource 1: technique video)
tip and just over the peroneal tendons. After dissection of the deep fascia, the peroneus longus tendon could be easily identified superficial to the peroneus brevis tendon. The peroneus longus tendon was then pulled out of the incision with a mosquito clamp (Fig. 1a) and the anterior half of the tendon (about 3.5–4.0 mm) was cut and split. A 2.0 Ethibond (Ethicon, Inc., Somerville, NJ, USA) suture was woven into the end of the anteriorly split tendon using a Krackow whip stitch (Fig. 1b). The route of the proximal portion of the tendon could be distinguished over the skin, and a second 1.5-cm transverse incision was made over the peroneus longus tendon 7 cm proximal from the initial incision. The proximal part of the peroneus longus tendon was pulled out through the second incision to keep the tendon under tension. Then, a 5-mm-wide tendon stripper was introduced over the 3.5 mm anterior portion of the peroneus longus tendon and pushed in a proximal direction through the incision underneath the tendon sheath (Fig. 1c). The anterior half of the peroneus longus tendon was pulled out through the second incision. A third 1.5 cm transverse incision was made over the peroneus longus tendon 7 cm proximal from the second incision. The tendon stripper was introduced again and pushed in a proximal direction. Finally, the anterior half of the peroneus longus tendon was pulled out through the third incision and transected. An approximately 14-cm-long free tendon could be harvested for lateral ankle ligament reconstruction (Online Resource 1: technique video). Lateral ankle ligament reconstruction technique After harvesting the anterior half of the peroneus longus tendon, lateral ankle reconstruction could be performed without changing the patient’s position. Lateral ankle ligament reconstruction was performed as described by Jung et al. [14]. A talar tunnel of 5-mm diameter and 20-mm depth was made on the anterior margin of the talar body at the ATFL attachment area. Two fibular tunnels were made at the footprint of the ATFL and CFL attachment. The
harvested anterior half of the peroneus longus tendon was passed through the proximal fibular tunnel, and the anterior end of the tendon was fixed into the talar tunnel at the ATFL attachment area with a 4.75-mm bioabsorbable interference screw (Arthrex Inc., Naples, FL, USA) to reconstruct the ATFL (Fig. 2). The tendon was sutured with the periosteum and the remnant tissue at the ATFL
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concentrate more on balance training and peroneal strengthening exercises. Clinical assessment
Fig. 2 Diagram showing lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon
footprint with the ankle in plantigrade neutral position. The remaining ATFL remnant was then laid over the graft and secured. The posterior end of the tendon was passed through the distal fibular tunnel. The tendon was then passed downward deep into the peroneal tendons. A 5-mm incision was made over the lateral calcaneal wall, and a 5.0-mm calcaneal tunnel was made. The tendon was inserted into the tunnel from lateral to medial and was tensioned with the ankle in plantigrade position and the subtalar joint in a neutral position. A 6.25-mm bioabsorbable interference screw (Arthrex) was then inserted from lateral to medial to reconstruct the CFL (Figs. 2, 3). All soft tissue layers were closed and the ankle was placed in a standard posterior splint. Post-operatively, the ankle was immobilized in a postoperative splint without weight bearing for 2 weeks, at which time the sutures were removed. Then, a short leg cast was applied in a neutral position for 2 weeks followed by soft ankle orthoses for another 4 weeks. Four weeks after surgery, active range of motion and partial weight bearing was allowed with a soft ankle orthosis. Gradually, full weight bearing was allowed. Balance training and proprioceptive exercises were encouraged. Before starting sports activities, when patients experienced ankle instability and a giving away sensation, they were advised to delay their sports activities and were encouraged to
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The Karlsson–Peterson ankle score was checked preoperatively and at final follow-up examination by an experienced physiotherapist blinded to the study details [16]. Patients were asked to rate their overall satisfaction with their surgical results as ‘‘very satisfied’’, ‘‘satisfied’’, ‘‘fair’’, or ‘‘dissatisfied’’. Radiographically, the anterior talar translation and the talar tilt angle were measured on the stress radiographs preoperatively and at final follow-up examination. Square-hop and side-hop tests were performed preoperatively and at final follow-up examination for 22 patients operated upon at one orthopaedic centre. At the final follow-up examination, the two tests were performed on the operated limb and on the contralateral uninjured limb, and results were compared to check for the peroneus longus function after anterior half of the peroneus longus tendon harvest (Online Resource 2, 3). For the square-hop test, a 40 9 40-cm square was marked on the floor with tape. Starting outside of the square, participants were instructed to hop on one limb in and out of the square, as fast as possible for five repetitions. One repetition constituted hopping in and out of the tape outline completely around the square back to the starting point. Before testing initiation, the test was demonstrated along with verbal instructions. To familiarize themselves with the protocol, patients performed one trial before the test. The time taken to complete the test was recorded using
Fig. 3 Intraoperative picture shows insertion of a bioabsorbable interference screw into the calcaneal tunnel with the posterior end of the anterior half of the peroneus longus tendon to reconstruct the CFL. Minimal incisions are enough for the autograft tendon harvest and the lateral ankle reconstruction
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a hand-held stopwatch to the nearest 0.01 s. The outcome measure was averaged over two trials. For the side-hop test, patients were instructed to hop on one limb laterally over a 30-cm distance. One repetition constituted hopping laterally to the 30 cm point and then back to the starting location. Each patient completed ten repetitions and was instructed to do so as quickly as possible. The outcome measure was averaged over two trials. The Korean Armed Forces Medical Command IRB (AFMC-13-IRB-009) approved the current study. Statistical analysis Statistical analysis was performed using SPSS version 12.0 (SPSS, SPSS Inc., Chicago, IL, USA) software. Data normality was assessed by the Kolmogorov–Smirnov test. The paired t test and Wilcoxon’s signed-rank test were used to compare preoperative and post-operative values (Karlsson– Peterson ankle score, and radiologic measurements). Statistical significance was accepted for p values \0.05.
Results The clinical and radiologic results are presented in Table 1. Fifteen patients (52 %) were very satisfied with the results, nine patients (31 %) were satisfied, four patients (14 %) were fair, and one patient (3 %) was dissatisfied with the results. One patient who was dissatisfied with the result had osteochondral lesion of the talus treated with arthroscopic microfracture at the time of lateral ankle reconstruction and still had deep ankle pain in the area of the osteochondral lesion. Four patients who gave a ‘‘fair’’ rating for the result did not return to their previous level of sports activity. However, all of them achieved mechanical stability on ankle stress radiographs. Seven patients noted developing ankle sprain after the operation. However, none of the patients required reoperation. Five of these injuries were mild sprains that did not require medication or Table 1 Clinical and radiologic results
Karlsson–Peterson ankle score (points)
Preoperative
Postoperative
p value
58.2 ± 10.9
83.9 ± 7.0
p \ 0.001
Stress radiograph Talar tilt angle (°) Anterior displacement (mm)
15.7 ± 3.5
4.6 ± 1.7
p \ 0.001
7.3 ± 2.6
4.1 ± 1.7
p \ 0.001
19.0 ± 2.0 11.5 ± 1.2
17.2 ± 1.1 10.3 ± 0.8
p \ 0.001 p \ 0.001
Functional performance test Square-hop test (s) Side-hop test (s)
immobilization. Five patients had tenderness on the bioabsorbable screw insertion site on the calcaneus when pressed, but this did not disturb activities. Four patients developed post-operative anterolateral ankle pain that lasted [6 months; however, in three of them, the pain subsided within 12 months. No patient complained of discomfort around the tendon harvest area during activities. None of the patients were suspected to have peroneus longus rupture. Twelve patients underwent ankle arthroscopy. Two patients had osteochondral lesions on the medial talus and were operated upon with microfracture bone marrow stimulation; three patients had os trigonum syndrome causing posterior impingement that was treated with posterior ankle arthroscopy; eight patients had anterolateral soft tissue impingement; and ten patients had synovitis. Two patients had anterior bony impingement treated with ankle arthroscopy and miniarthrotomy for resection of the bony spurs. At the last follow-up examination, square-hop and sidehop tests were performed on both the tendon harvested limb and the contralateral uninjured limb, and results were compared to check for the peroneus longus function after the anterior half of the peroneus longus tendon harvest. No significant difference was observed in the square-hop test (n.s.) between the tendon harvested limb (17.2 ± 1.1 s) and the contralateral limb (16.9 ± 1.6 s). Similarly no significant difference was observed in the side-hop test (n.s.) between the tendon harvested limb (10.3 ± 0.8 s) and the contralateral limb (10.2 ± 0.8 s).
Discussion The most important findings of the present study was that lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon showed significant improvements in Karlsson–Peterson ankle score and achieved mechanical stability without significant complications. The anterior half of the peroneus longus tendon could be easily harvested through one of the percutaneous incisions required for ankle reconstruction without the need for patient repositioning. Lateral ankle reconstruction could be accomplished through a small curvilinear incision similar to the incision for the Brostro¨m procedure with the addition of two percutaneous incisions. Lateral ankle ligament reconstruction using an allograft or autograft tendon is recommended for patients with chronic lateral ankle instability with severely attenuated or deficient lateral ankle ligaments, which are expected to have a poor outcome with direct ligament repair alone [1, 11, 14] Although the modified Brostro¨m procedure is widely used for the surgical treatment of chronic lateral
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ankle instability, contraindications have now been suggested after further experience with this direct ligament repair, including failed previous reconstructive surgery, the presence of long-standing ankle instability, generalized ligamentous laxity or increased size or weight [1, 11, 14]. Remnants of the ruptured ligaments degenerate over time and are therefore sometimes inadequate for use as reconstructive material because of both their low tensile force and shortening with respect to normal length [23]. When a large ossicle is present within the lateral ligaments, removal of the ossicle can result in a lack of remnant ligamentous tissue and leave a gap within the ATFL and CFL that may not be approximated [18]. These conditions can be the indications for lateral ankle ligament reconstruction augmented by an allograft or autograft tendon. Many techniques of lateral ankle ligament reconstruction with various autograft tendons or allograft tendon have reportedly shown satisfactory results [1, 11, 28]. However, we believe our technique has several important advantages worth mentioning. First, the small curvilinear incision used in our technique is small compared with the incisions used in other reconstruction techniques and is similar to the incision for the Brostro¨m procedure. Minimal incision results in less post-operative swelling and pain [30]. Our technique enables the use of the small curvilinear incision for the Brostro¨m procedure and when attenuated or deficient lateral ligaments are found intraoperatively, conversion to reconstruction is straightforward with the addition of two percutaneous incisions. Second, the anterior half of the peroneus longus tendon can be easily harvested and used for the reconstruction since the peroneus longus tendon is superficial in the distal leg and has no juncturae and adherence to the surrounding soft tissue. Furthermore, harvest of the anterior half of the peroneus longus tendon can be achieved through one of the percutaneous incisions for the lateral ankle reconstruction without changing the patient’s position. Therefore, in an unexpected condition such as inadequate lateral ligaments for repair being found intraoperatively, without the allograft being prepared at the time of operation, anterior half of the peroneus longus tendon can be easily harvested and used for the reconstruction. One of the widely used autograft sources for the ankle reconstruction is the gracilis tendon [6, 11, 28]. The gracilis tendon provides an excellent graft source for reconstruction as the usable length of this tendon is [20 cm, which is enough to reconstruct both the ATFL and CFL. The strength and the diameter of the tendon are suitable for reconstruction without the need to weave the tendon several times, as is needed for tendons with a smaller diameter such as the plantaris or extensor digitorum longus tendons. Minimum donor site morbidity has been reported when the gracilis tendon is harvested for
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anterior cruciate ligament (ACL) reconstruction. However, to harvest a gracilis tendon when reconstruction is decided intraoperatively after the inspection of the lateral ligaments, the patient’s position has to be changed from a semilateral or lateral position to a supine position for the harvest, and then back to the semilateral or lateral position for the reconstruction. With our technique of using the anterior half of the peroneus longus tendon, this position change is not necessary. When the surgeon is not familiar with the local anatomy around the knee, inadvertent saphenous nerve injury during the harvesting procedures may result in numbness around the harvest site, and precutting of the tendon may occur when detaching the juncturae connected to the tendon. The plantaris or extensor digitorum longus tendon can be used [1, 3, 21, 27]; however, the plantaris tendon can be absent in up to 19 % of cases [1]. The extensor digitorum longus tendon is sometimes difficult to harvest owing to juncturae and its adherence to the surrounding soft tissue. The resultant postoperative weakness of the toe extension can be a disadvantage [1]. The use of an allograft tendon allows a shorter operation time and prevents donor site morbidity. However, it raises issues of possible disease transmission and high cost. Exogenous material bears the risks of hypersensitivity, local inflammation, or infection. It is sometimes not a reliable alternative given the relative shortage of such grafts [14]. The anterior half of the peroneus longus tendon has been reported to be an acceptable alternative for autograft use with respect to its strength, safety, and donor site morbidity. The strength of the anterior half of the peroneus longus tendon is greater than that of the gracilis tendon. In a cadaveric study, the failure load of the anterior half of the peroneus longus tendon accounted for 97.69 and 147.94 % of the semitendinosus and gracilis tendons, respectively [30]. A study of 92 patients who underwent a variety of knee ligament reconstructions with the anterior half of the peroneus longus tendon autograft and followed up for [2 years revealed that there was no significant impairment of the foot and ankle function after the harvest of the anterior half of the peroneus longus tendon. The clinical study showed that the preoperative and post-operative American Orthopedic Foot and Ankle Society scores were 97.4 ± 2.0 and 97.2 ± 1.6 (n.s.), respectively, whereas the preoperative and post-operative Foot and Ankle Disability Index scores were 96.8 ± 2.2 and 96.9 ± 2.5 (n.s.), respectively. No signs of peroneal nerve injury, peroneus longus tendon rupture, or tendinopathy were found [31]. There are disadvantages to using anterior half of the peroneus longus tendon for lateral ankle reconstruction. Disturbing one of the evertor and dynamic lateral ankle stabilizer can have drawbacks. However, we believe lateral ankle ligament reconstruction with the anterior half of the
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peroneus longus tendon is a better option than using the peroneus brevis tendon for non-anatomical reconstruction, since the peroneus brevis is a more effective evertor than the peroneus longus [7, 17]. Peroneus brevis is the primary dynamic stabilizer of the ankle joint and should therefore remain intact and undisturbed whenever possible [17]. Although the peroneus longus tendon is one of the dynamic lateral ankle stabilizers, the clinical results of using split peroneus longus tendon for lateral ankle reconstruction have been satisfactory [7, 17]. One study of 25 consecutive patients who underwent autologous split peroneus longus lateral ankle stabilization reported that 92 % demonstrated good to excellent outcomes in a mean follow-up period 29.5 months [7]. The posterior limb of the split peroneus longus tendon was rerouted through an osseous tunnel to reconstruct the lateral ligaments. Kennedy et al. [17] harvested a 4.5-cm-long and 4-mm-thick band of the peroneus longus tendon from around the posteroinferior corner of the lateral malleolus and reconstructed the ATFL for 57 patients with chronic lateral ankle instability. At a mean follow-up period of 32 months, the Foot and Ankle Outcome Score improved from 58 points to 89 points and the Short Form-12 score from 48 to 80 points. The results of the current study in a series of 31 ankles are encouraging, with 24 of 29 (83 %) patients being very satisfied or satisfied with the results of using anterior half of the peroneus longus tendon for reconstruction. The Karlsson-Peterson ankle score significantly improved by a mean 25.6 ± 12.8 points (p \ 0.001). Mechanical stability was achieved. Functional performance significantly improved for squarehop test and for side-hop test. The stability of the ankle joint is commonly assessed by the anterior drawer test or the varus stress test. Although these tests are useful for assessing ankle joint instability caused by a ligament tear, they are unable to evaluate the degree of joint instability during dynamic activity, which is controlled not only by static factors such as the ligaments but also by dynamic factors such as muscle strength, reaction time, or stiffness. Square-hop test and side-hop test were performed preoperatively and at final follow-up examination to check for the dynamic factors. Functional performance tests including the square-hop test and the side-hop test consist of jumping, landing, and cutting activities that produce a high load on the joints of the lower leg. Many studies have reported that these tests can be used to determine the presence of functional ankle instability [8, 25, 29]. In a study of 62 athletes (31 with functional ankle instability, 31 without functional ankle instability), significant performance differences were found between subjects with functional ankle instability and healthy subjects in the square-hop test and side-hop test. The test–retest reliability determined by intraclass correlation coefficient was 0.90 for the square-hop test and 0.84
for the side-hop test [25]. Furthermore, in the current study, the two tests were performed on the anterior half of the peroneus longus tendon harvested limb and on the contralateral uninjured limb at the final follow-up examination and were compared to check if the anterior half of the peroneus longus tendon harvest led to impairment of peroneus longus function to a degree causing functional impairment of ankle stability. No significant difference was observed between the anterior half of the peroneus longus tendon harvested limb and the non-harvested limb in the square-hop test (n.s.) and the side-hop test (n.s.) at the last follow-up examination. Therefore, functional performance could have not been impaired after anterior half of the peroneus longus tendon harvest or recovered at the last follow-up examination. Yoshida et al. [29] evaluated muscle activity during the side-hop test using electromyography. The peroneus longus was activated at approximately 120–160 % of the maximal voluntary contraction (the maximal voluntary contraction of the peroneus longus was measured with the subject in a sitting position with the foot plantar flexed to 10°–20° and then everted) during the contact phase and 50–80 % of the maximal voluntary contraction during the flight phase of the side-hop test which reveals that peroneus longus is largely involved during the test and that peroneus longus activity is largely required to perform the test. A study of 92 patients who underwent a variety of knee ligament reconstructions with the anterior half of the peroneus longus tendon autograft and were followed up for [2 years revealed that no significant impairment of the foot and ankle function was observed after the harvest of the anterior half of the peroneus longus tendon, and only one patient had an ankle sprain 15 months after surgery with no clear association found between this ankle sprain and the previous anterior half of the peroneus longus tendon harvest [31]. However, we acknowledge that the two functional performance tests performed in the current study cannot evaluate the function of peroneus longus alone after anterior half of the peroneus longus tendon harvest and that there is no existing method to check the function of the peroneus longus alone [20]. Another limitation of the current study is that seven patients in the study had bilateral ankle instability and this could be a confounding variable not controlled in the study. These patients could have shown better functional performance on their anterior half of the peroneus longus tendon harvested limb compared with the contralateral limb with ankle instability. The small number of subjects is another limitation of this study. Another disadvantage of using the anterior half of the peroneus longus tendon for reconstruction is that it may not be adequate to use the anterior half of the peroneus longus tendon when there are splits or tears in the peroneus longus tendon. When these pathologies were suspected from
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physical examination and MRI results, we did not harvest the anterior half of the peroneus longus tendon because of the risk of tendon rupture. However, none of these pathologies have been previously reported after anterior half of the peroneus longus tendon harvest for ACL reconstruction or split peroneus longus tendon lateral ankle stabilization. In the current study, none of these pathologies were suspected after the harvest at the final follow-up examination. Peterson et al. [22] reported that the peroneus longus tendon has two avascular zones, one located in the region where the tendon turns around the lateral malleolus and the other located where the tendon turns around the cuboid. These are the common sites of tendon rupture and tenosynovitis occurrences. With our technique of harvesting the anterior half of the peroneus longus tendon from 3 cm proximal from the distal tip of the lateral malleolus, the portion of the tendon that turns around the lateral malleolus is kept intact and the posterior portion where the blood supply enters remains undisturbed. Therefore, post-operative tendon rupture or tenosynovitis are less likely to develop with our technique compared with the other peroneus longus tendon harvesting techniques, such as that from the posterior portion of the peroneus longus tendon around the posteroinferior corner of the lateral malleolus, or split peroneus longus lateral ankle stabilization using the posterior limb of the peroneus longus tendon for the reconstruction [7, 17]. This study is limited by its retrospective, non-comparative nature. Furthermore, this study is limited by the small number of subjects and the short follow-up period. However, the results of the current procedures in a series of 31 ankles are encouraging. The facts that the anterior half of the peroneus longus tendon can be harvested easily through the incision for lateral ligament reconstruction without the need for repositioning is a considerable advantage of this technique. Although we cannot recommend the current surgical procedure as a preferred method for chronic lateral ankle instability without a prospective comparative study, we believe that using the anterior half of the peroneus longus tendon for lateral ankle reconstruction is a better option than using the peroneus brevis tendon for nonanatomic reconstruction. In an unexpected condition such as inadequate lateral ligaments for Brostro¨m repair being found intraoperatively, without the allograft being prepared at the time of operation, anterior half of the peroneus longus tendon can be easily harvested and used for the reconstruction.
Conclusion Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon can be a surgical option for chronic ankle instability with attenuated or deficient
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ligaments that the modified Brostro¨m procedure cannot be performed.
References 1. Ahn JH, Choy W, Kim H (2011) Reconstruction of the lateral ankle ligament with a long extensor tendon graft of the fourth toe. Am J Sports Med 39(3):637–644 2. Ajis A, Younger AS, Maffulli N (2006) Anatomic repair for chronic lateral ankle instability. Foot Ankle Clin 11(3):539–545 3. Anderson ME (1985) Reconstruction of the lateral ligaments of the ankle using the plantaris tendon. J Bone Joint Surg Am 67(6):930–934 4. Beighton P, Horan F (1969) Orthropaedic aspects of the EhlersDanlos syndrome. J Bone Joint Surg Br 51:444–453 5. Bohnsack M, Su¨rie B, Kirsch L, Wu¨lker N (2002) Biomechanical properties of commonly used autogenous transplants in the surgical treatment of chronic lateral ankle instability. Foot Ankle Int 23(7):661–664 6. Boyer DS, Younger AS (2006) Anatomic reconstruction of the lateral ligament complex of the ankle using a gracilis autograft. Foot Ankle Clin 11(3):585–595 7. Budny AM, Schuberth JM (2012) Autologous split peroneus longus lateral ankle stabilization. J Foot Ankle Surg 51(5):588–592 8. Caffrey E, Docherty CL, Schrader J, Klossner J (2009) The ability of 4 single-limb hopping tests to detect functional performance deficits in individuals with functional ankle instability. J Orthop Sports Phys Ther 39(11):799–806 9. Caprio A, Oliva F, Treia F, Maffullin N (2006) Reconstruction of the lateral ankle ligaments with allograft in patients with chronic ankle instability. Foot Ankle Clin 11(3):597–605, 2007:1455–1458 10. Colville MR (1998) Surgical treatment of the unstable ankle. J Am Acad Orthop Surg 6(6):368–377 11. Coughlin MJ, Schenck RC, Grebing BR, Treme G (2004) Comprehensive reconstruction of the lateral ankle for chronic instability using a free gracilis graft. Foot Ankle Int 25(4):231–241 12. Espinosa N, Smerek J, Kadakia AR, Myerson MS (2006) Operative management of ankle instability: reconstruction with open and percutaneous methods. Foot Ankle Clin 11(3):547–565 13. Ibrahim SA, Hamido F, Al Misfer AK, Ghafar SA, Awad A, Salem HKh, Alhran H, Khirait S (2011) Anatomical reconstruction of the lateral ligaments using Gracilis tendon in chronic ankle instability; a new technique. Foot Ankle Surg 17(4):239–246 14. Jung HG, Kim TH, Park JY, Bae EJ (2012) Reconstruction of the anterior talofibular and calcaneofibular ligaments using a semitendinosus tendon allograft and interference screws. Knee Surg Sports Traumatol Arthrosc 20(8):1432–1437 15. Karlsson J, Eriksson BI, Bergsten T, Rudholm O, Swa¨rd L (1997) Comparison of two reconstructions for chronic lateral instability of the ankle joint. Am J Sports Med 25(1):48–53 16. Karlsson J, Peterson L (1991) Evaluation of ankle joint function: the use of a scoring scale. The Foot 1(1):15–19 17. Kennedy JG, Smyth NA, Fansa AM, Murawski CD (2012) Anatomic lateral ligament reconstruction in the ankle: a hybrid technique in the athletic population. Am J Sports Med 40(10):2309–2317 18. Kim BS, Choi WJ, Kim YS, Lee JW (2010) The effect of an ossicle of the lateral malleolus on ligament reconstruction of chronic lateral ankle instability. Foot Ankle Int 31(3):191–196
Knee Surg Sports Traumatol Arthrosc 19. Krips R, van Dijk CN, Halasi T, Lehtonen H, Moyen B, Lanzetta A, Farkas T, Karlsson J (2000) Anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a 2- to 10-year follow-up, multicenter study. Knee Surg Sports Traumatol Arthrosc 8(3):173–179 20. Lo¨fvenberg R, Ka¨rrholm J, Sundelin G, Ahlgren O (1995) Prolonged reaction time in patients with chronic lateral instability of the ankle. Am J Sports Med 23(4):414–417 21. Pagenstert GI, Hintermann B, Knupp M (2006) Operative management of chronic ankle instability: plantaris graft. Foot Ankle Clin 11(3):567–583 22. Petersen W, Bobka T, Stein V, Tillmann B (2000) Blood supply of the peroneal tendons: injection and immunohistochemical studies of cadaver tendons. Acta Orthop Scand 71(2):168–174 23. Sammarco GJ, Idusuyi OB (1999) Reconstruction of the lateral ankle ligaments using a split peroneus brevis tendon graft. Foot Ankle Int 20(2):97–103 24. Sekir U, Yildiz Y, Hazneci B, Ors F, Saka T, Aydin T (2008) Reliability of a functional test battery evaluating functionality, proprioception, and strength in recreational athletes with functional ankle instability. Eur J Phys Rehabil Med 44(4):407–415 25. Sharma N, Sharma A, Sandhu J (2011) Functional performance testing in athletes with functional ankle instability. Asian J Sports Med 2(4):249–258
26. Snook GA (1985) Long-term results of the Chrisman-Snook operation for reconstruction of the lateral ligaments of the ankle. J Bone Joint Surg Am 67(1):1–7 27. Takahashi T, Nakahira M, Kaho K, Kawakami T (2003) Anatomical reconstruction of chronic lateral ligament injury of the ankle using pedicle tendon of the extensor digitorum longus. Arch Orthop Trauma Surg 123(4):175–179 28. Takao M, Oae K, Uchio Y, Ochi M, Yamamoto H (2005) Anatomical reconstruction of the lateral ligaments of the ankle with a gracilis autograft: a new technique using an interference fit anchoring system. Am J Sports Med 33(6):814–823 29. Yoshida M, Taniguchi K, Katayose M (2011) Analysis of muscle activity and ankle joint movement during the side-hop test. J Strength Cond Res 25(8):2255–2264 30. Youn H, Kim YS, Lee J, Choi WJ, Lee JW (2012) Percutaneous lateral ligament reconstruction with allograft for chronic lateral ankle instability. Foot Ankle Int 33(2):99–104 31. Zhao J, Huangfu X (2012) The biomechanical and clinical application of using the anterior half of the peroneus longus tendon as an autograft source. Am J Sports Med 40(3):662–671
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