540145
research-article2014
FAIXXX10.1177/1071100714540145Foot & Ankle InternationalXu et al
Article
Minimally Invasive Reconstruction of the Lateral Ankle Ligaments Using Semitendinosus Autograft or Tendon Allograft
Foot & Ankle International® 2014, Vol. 35(10) 1015–1021 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100714540145 fai.sagepub.com
Xiangyang Xu, PhD1, Mu Hu, MD1, Jinhao Liu, MD1, Yuan Zhu, MD1, and Bibo Wang, MD1
Abstract Background: The purpose of the study was to retrospectively compare the therapeutic effect between semitendinosus autograft and tendon allograft for lateral ankle ligaments reconstruction. Methods: From September 2006 to June 2011, 68 patients (41 males, 27 females) with chronic ankle instability underwent anatomical reconstruction of the lateral ligaments using semitendinosus autograft (autograft group, 32 patients) or tendon allograft (allograft group, 36 patients) via a minimally invasive approach. All patients were followed up for at least 12 months. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score (AOFAS score) and stress tests were used to evaluate the clinical outcomes. Operation time, time to heal and complications were also recorded. Results: Compared with allograft group, the average operation time was significantly increased (85.5 ± 11.5 minutes vs 58.1 ± 10.2 minutes, P < .0001), but the mean time to heal was significantly shorter (11.2 ± 4.1 months vs 13.5 ± 5.2 months, P = .0458) in the autograft group. Although the mean AOFAS score was significantly increased at the final followup in the autograft group (95.1 ± 7.5 vs 62.3 ± 8.2, P = .0001) and allograft group (94.8 ± 5.5 vs 60.2 ± 8.4, P < .0001), no significant difference in AOFAS was found between these 2 groups. Similarly, there was no significant difference in talar tilt or shift between autograft and allograft groups. In addition, no patients complained of weakness or disability at the donor site in the autograft group, while incisional swelling was observed in 4 patients in the allograft group, which was resolved via dressing change, oral use of indomethacin or dexamethasone. Conclusion: Reconstruction of the lateral ankle ligaments using a semitendinosus tendon autograft and a minimally invasive approach was safe and effective for ankle instability with a relatively short time for healing and minimal donor site problems. Level of Evidence: Level III, comparative case series. Keywords: lateral ankle instability, ligament reconstruction, semitendinosus autograft, tendon allograft Acute ankle sprain is a common condition in which the ligaments of the ankle are completely or partially torn, accounting for approximately 15% of sports-related injuries.20 Bridgman et al3 reported that the incidence of ankle sprains is 60.9 per 10 000 in the United Kingdom, of which 14% are classified as severe (ie, 42 000 severe ankle sprains per year). Although most of the patients have satisfactory functional recovery after conservative treatment, some of them show mechanical instability and require operative intervention after several years.15 Currently, there are multiple operative techniques for chronic ankle instability, including anatomic repair (eg, Broström,2 Karlsson modified Broström,18 and Gould modified Broström4), nonanatomic reconstruction (eg, Chrisman-Snook21 and Evans procedures11), and anatomic
reconstruction. Anatomic repair uses the existing ligamentous tissues to restore the stability. If there is inadequate soft tissues due to repetitive ankle sprains or surgeries, reconstruction may be preferable to repair. Nonanatomic reconstruction stabilizes the ankle utilizing the peroneus brevis tendon, but does not reestablish the ankle kinematics, 1
Department of Orthopaedics, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China Xiangyang Xu and Mu Hu are co–first authors. Corresponding Author: Xiangyang Xu, PhD, Department of Orthopaedics, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Hao, RuiJin Er Rd, Shanghai 200025, China. Email: [email protected]
Downloaded from fai.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
1016
Foot & Ankle International 35(10)
Table 1. Comparison of Clinical Manifestation of Patients in Autologous and Allograft Groups. Comparability Clinical manifestation Gender (male/female) Average age (years) Injured ankle (left/right) Body mass index Time of initial injury to surgery (months) Operation outcome Operation time (minutes) Duration of fever (days) Time to heal (months) Follow-up Patients Duration
Autograft Group
Allograft Group
32 (19/13) 32.4 ± 2.4 14/18 28.7 ± 4.0 17.3 ± 2.1
36 (22/14) 33.2 ± 3.2 16/20 30.5 ± 5.2 19.1 ± 4.9
85.5 ± 11.5 2.5 ± 1.2 11.2 ± 4.1
58.1 ± 10.2 5.5 ± 1.5 13.5 ± 5.2
23 33.5 ± 6.7
26 28.5 ± 6.7
P Value .884 .2525 1.000 .1178 .058 .0000 .0000 .0458 .0122
possibly resulting in ankle stiffness.30,32 Subsequently, some have described an anatomic reconstruction using autograft33 or allograft tendon.14 Studies have demonstrated that anatomic reconstruction can not only significantly reduce both lateral ankle instability and talar tilt, but also lead to recovery of normal motion.29 The most common autograft tendons used are the extensor tendon of the fourth toe,1 plantaris,8 and semitendinosus.33 Meanwhile, allograft tendons mainly include tibialis anterior tendon allograft9 and semitendinosus tendon allograft.16 Previous studies have shown that there are no significant differences in short-term clinical outcomes between allograft and autograft tendon.5 Importantly, an allograft has the advantages of no donor site morbidity, shorter operation time and less postoperative pain compared with the autograft.25 Thus, allograft tendon has become a more common option. However, a recent expected-value decision analysis indicate patients’ aversion to allograft in general and decision to use autograft for anterior cruciate ligament reconstruction independent of expected outcomes.28 Therefore, it is necessary to develop a minimally invasive surgery for autograft tendon to reduce the tendon donor site problems, which was achieved in a previous study.33 In the present study, we aimed to further compare the clinical outcome of anatomical reconstructions of the lateral ankle ligaments using semitendinosus autograft or tendon allograft (Osteorad Ltd, Shanxi, China) via a minimally invasive approach retrospectively.
after we introduced the advantages and disadvantages of both methods. The autograft group included 19 males and 13 females with an average age of 32.4 ± 2.4 years, and the allograft group included 22 males and 14 females with an average age of 33.2 ± 3.2 years. The average time of initial injury to surgery was 17.3 ± 2.1 months in the autograft group and 19.1 ± 4.9 months in the allograft group. In the autograft group, 23 patients were followed an average of 33.5 ± 6.7 months, while 26 patients in the allograft group were followed an average of 28.5 ± 6.7 months (Table 1). The indications for surgery were (1) recurrent sprains more than twice within half a year; (2) severe ankle instability by a positive anterior drawer test (10 mm talar shift or 3 mm more than healthy side) or talar tilt (talar tilt > 9 degrees or 3 degrees more than healthy side);17 (3) failure of conservative treatments (rest, ice, compression, elevation, and support), or Broström and Gould surgeries (5 patients in autograft group and 7 patients in allograft group); and (4) obesity (body mass index > 25).23 All patients with the following surgery contraindications were excluded: (1) ankle infection, (2) fracture, and (3) ankle arthritis > grade 2 according to Morrey and Wiedeman classification.22 In addition, all patients underwent weight-bearing radiographs (anterior-posterior, mortise, and lateral views) of foot, gait analysis, and physical exam evaluation for injuries of anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL), such as swelling, congestion, and tenderness preoperatively.
Methods
Procedure
From September 2006 to June 2011, 68 patients having lateral ankle instability were treated via anatomical reconstruction of the lateral ligaments of the ankle in our hospital. These patients received the semitendinosus autograft (autograft group, 14 left/18 right) or tendon allograft (allograft group, 16 left/20 right) according to their financial situation
An arthroscopic-assisted minimally invasive surgery was performed on all patients as described in a previous study.33 After general or continual epidural anesthesia, the patients were placed supine and the knee of affected limb was flexed and rotated laterally. A tourniquet was routinely applied at the proximal thigh.
Downloaded from fai.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
1017
Xu et al
Figure 1. Stress test for examination of lateral ankle instability under arthroscopy. (A) Talar tilt test. (B) Anterior drawer test.
Figure 2. The semitendinosus tendon autograft was harvested with a minimally invasive technique. (A) Distal end of semitendinosus tendon. (B) Proximal end of semitendinosus tendon.
After verifying ankle instability by anterior drawer or talar tilt test under arthroscopy (Figure 1), the semitendinosus tendon was harvested from the ipsilateral affected limb via a 2-incision technique (Figure 2) in which the proximal incision was made at the most medial tendon 2 cm above the joint line and the distal incision was made 2 cm medial to the tibial tuberosity. After the 2 ends of the tendon were exposed, the semitendinosus tendon was isolated using a
specialized tendon stripper, released from the distal end, extracted from the proximal incision, and finally immersed in physiological saline until use after being woven with the 2-0 absorbable muscle-tendon suture (Johnson & Johnson Medical Ltd, Sommerville NJ, USA). The allograft ligament purchased from Osteorad Ltd (Shanxi, China) was trimmed to 14 cm (in length) × 8 mm (in width) × 1 mm (in thickness) after cryogenic processing and then woven
Downloaded from fai.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
1018
Foot & Ankle International 35(10)
through the 2-0 absorbable muscle-tendon suture (Johnson & Johnson Medical Ltd, Sommerville NJ, USA). At the recipient site of the ankle, 4 small incisions (5 mm in diameter) were made at the medial and lateral side of the fibular tip, the talar neck, and the middle portion of the calcaneus (Figure 3). Two guide wires were introduced transversely at the distal end of the fibula. Two holes were then drilled over the guide wire from each end to form a tunnel (4.5 mm in diameter, incline of 120 degrees). The prepared semitendinosus tendon autograft was introduced through the tunnel by a long eyelet needle. The ends of the tendon were then passed above the bone surface to the incisions at the talar neck and calcaneus. Guide wires were placed for positioning of talar and calcaneal tunnels under C-arm fluoroscopy. A 7 mm × 23 mm biodegradable inference screw (polyl-l-lactic acid, BioCryl®, DePuy Mitek, Raynham, MA) was used to fix the tendon graft in the talar neck and calcaneus. The location of interference screws was also detected under C-arm fluoroscopy.
Postoperative Management After operation, smoking was prohibited. The affected foot was immobilized in a valgus position and a weightfree manner using a U-shaped plaster. Antibiotics were routinely used for 24 hours after operation. Isometric dorsiflexion strengthening of the ankle was allowed to reduce stiffness at 3 days after operation. Four weeks after surgery, the cast was changed to an ankle orthosis and partial weight-bearing exercises were encouraged. Six weeks after the surgery, full weight-bearing exercises were permitted. The ankle orthosis was removed at 10 weeks after operation, and walking with a soft brace (Company OPED, Valley, Germany) was allowed. Jogging was resumed at 12 weeks after operation.
Clinical Evaluation The operative data between the groups were recorded and analyzed, including operation time (minutes), duration of any fever (>37°C, days), time to heal (could walk on uneven ground steadily in months), and complications. The outcome of operative treatment was evaluated using the clinical rating scale of the American Orthopaedic Foot and Ankle Society (AOFAS, 100 points total).19 Donor site morbidity was assessed by subjective sensation at the donor site area, range of motion of the knee and strength. Postoperative stress radiographs were taken using a TELOS stress device (TELOS, METAX, Germany) at 150 N.
Statistical Analysis Statistical analysis was performed using SPSS 13.0 software (Chicago, IL). The Wilcoxon and signed tests were
used for statistical analysis of pre- and postoperative AOFAS. The significance level was defined as P < .05.
Results Compared with the allograft group, the average operation time was significantly increased (85.5 ± 11.5 minutes vs 58.1 ± 10.2 minutes, P < .0001), but the fever days and time to heal were significantly shorter (2.5 ± 1.2 days vs 5.5 ± 1.5 days, P < .0001; 11.2 ± 4.1 months vs 13.5 ± 5.2 months, P = .0458) in the autograft group (Table 1). At the final follow-up, the mean AOFAS score in the autograft group was significantly increased compared with preoperation (95.1 ± 7.5 vs 62.3 ± 8.2, P < .0001), as well as the allograft group (94.8 ± 5.5 vs 60.2 ± 8.4, P < .0001) (Table 2). However, no significant difference in the AOFAS score was found between the 2 groups preoperatively and at the final follow-up. Three patients in the autograft group and 2 in the allograft group reported residual instability on uneven ground. One patient in the autograft group walked unsteadily in daily life. No patients complained of weakness or disability at the donor site. Compared with preoperation, the stress radiography showed a significant reduction of both talar tilt (from 14.0 ± 3.2 degrees to 3.8 ± 1.2 degrees) and shift (12.3 ± 3.2 mm to 4.6 ± 1.2 mm) at the final follow-up in the autograft group as well as the allograft group (talar tilt from 13.0 ± 3.5 degrees to 3.6 ± 1.4 degrees; talar shift from 11.5 ± 2.3 mm to 4.3 ± 1.5 mm) (Table 2). However, there was also no significant difference in talar tilt or shift between autograft and allograft groups. Despite the greater number of ever days and time to heal needed in the allograft group, no evidence of sterile effusion overlying the absorbable screws was detected. The incisions were normally healed in most patients due to only mild rejection using cryogenically preserved allograft. Incisional swelling lasted for 5 to 10 days in 4 patients, which resolved via dressing change, oral use of indomethacin, or dexamethasone. No incisional complications were noted in the autograft group. No patient required reoperation.
Discussion Although several studies have demonstrated no significant differences in clinical outcomes between allograft and autograft tendon for reconstruction of the lateral ankle ligaments, allograft reconstruction is significantly more expensive than autograft reconstruction24 and has the potential for disease transmission, limiting its acceptance for routine ankle reconstruction.26 Therefore, autograft tendon is still preferable for most patients. To reduce the disadvantages of autograft tendon (donor site morbidity), we described a minimally invasive approach for reconstruction
Downloaded from fai.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
1019
Xu et al
Figure 3. Anatomical anterior talofibular ligament (ATFL) and calcaneofibular ligament reconstruction by semitendinosus tendon autograft with a minimally invasive technique. (A) 4 small incisions (5 mm) at the lateral malleolus. (B) Tendon loaded on eyelet needle for passage of the graft traction suture and tendon through distal fibula. (C) Tendon with traction suture at both ends. Middle part of tendon is inside distal fibular tunnel. (D) Clamp 2 guides clamp 1 through the subcutaneous tunnel. Then clamp 1 holds traction suture and leads tendon through tunnel to talar neck. (E) Interference screw was used to fix 1 end of tendon to the talus to reconstruct ATFL. (F) The other end of tendon was introduced into body of calcaneus. (G) The foot was slightly everted while inserting the interference screw into the calcaneus to keep the tension on lateral ligament.
Downloaded from fai.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
1020
Foot & Ankle International 35(10)
Table 2. AOFAS Score, Talar Tilt, and Talar Shift at Preoperation and Final Follow-Up.
AOFAS score (point) Preoperatively Final follow-up Talar tilt (degrees) Preoperatively Final follow-up Talar shift Preoperatively Final follow-up
Autograft Group
Allograft Group
62.3 ± 8.2 95.1 ± 7.5
60.2 ± 8.4 94.8 ± 5.5
14.0 ± 3.2 3.8 ± 1.2
13.0 ± 3.5 3.6 ± 1.4
12.3 ± 3.2 4.6 ± 1.2
11.5 ± 2.3 4.3 ± 1.5
P Valuea .0000 .0000 .0000 .0000 .0000 .0000
a
Compared with preoperatively.
of the lateral ligaments of the ankle using a semitendinosus autograft.33 The semitendinosus tendon is relatively easy to harvest and it is larger in diameter and provides a stronger graft for simultaneous reconstruction of the ATFL and CFL.6 Previous studies have demonstrated minimal donor site morbidity using the semitendinosus tendon.27 As expected, our results showed that no patients complained of weakness or disability at the donor site. Consistent with previous literature,5,10 our clinical results also showed no significant differences in the AOFAS scores, talar tilt, and talar shift between autograft and allograft groups. In addition, because additional time was required for autograft graft preparation, the average operation time was significantly increased in the autograft group compared with allograft group. Thus, some scholars believe that the cost of the allograft itself appears to be offset by the increased operating room time and a greater likelihood of overnight hospitalization for autograft procedures.7 However, a recent expected-value decision analysis demonstrated patients’ aversion to allograft tissue in general.28 This may be attributed to more febrile days and time to heal in the allograft group. The longer fever may be associated with the host immune response to the allograft and the ability of tissue banks in our country to process allografts.31 The exact reason needs to be further studied. The different collagen content and mechanical strength of the allograft tendon from the native ankle ligaments contributed to the greater time to heal, which may influence patients’ quality of life and return to work.13 Yamazaki et al reported that an increase in the length of the bone tunnel was positively correlated with the quality and strength of the reconstruction.34 Minimizing the mismatch of diameters between graft and tunnel may tighten the fit of the graft in the tunnel and improve healing.12 In this study, a 4.5 mm drill was used to create a tunnel that could be widened to 7 mm with an approximate depth of 23 mm. A 7 mm × 23 mm biodegradable interference
screw was used to fix the tendon graft in the talar neck and calcaneus. Thus, the time to heal was shorter in the autograft group, and no major postoperative complications (talar neck fractures, osteolysis, or sterile drainage) occurred. This study had several limitations. The first was the retrospective nature of the study which contributed to the different follow-up times in 2 groups. Second, the follow-up time of both groups was relatively short so long term follow-up should be done to further evaluate their outcomes. Third, the sample size was small. In conclusion, we retrospectively analyzed the effectiveness of semitendinosus autograft and tendon allograft used for anatomic reconstruction of the lateral ligaments for chronic ankle instability. Combined with the minimally invasive surgery, the healing of the semitendinosus autograft was slightly faster than the tendon allograft and minimal donor site morbidity was observed. The clinical outcomes of the 2 grafts were both excellent, and no significant difference was identified. However, further multicenter study is still needed with a larger sample size and longer follow-up. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Ahn JH, Choy W-S, Kim H-Y. Reconstruction of the lateral ankle ligament with a long extensor tendon graft of the fourth toe. Am J Sports Med. 2011;39(3):637-644. 2. Bell SJ, Mologne TS, Sitler DF, Cox JS. Twenty-six-year results after Broström procedure for chronic lateral ankle instability. Am J Sports Med. 2006;34(6):975-978. 3. Bridgman S, Clement D, Downing A, et al. Population based epidemiology of ankle sprains attending accident and emergency units in the West Midlands of England, and a survey of UK practice for severe ankle sprains. Emerg Med J. 2003;20(6):508-510. 4. Brodsky AR, O’Malley MJ, Bohne WH, Deland JA, Kennedy JG. An analysis of outcome measures following the BroströmGould procedure for chronic lateral ankle instability. Foot Ankle Int. 2005;26(10):816-819. 5. Carey JL, Dunn WR, Dahm DL, Zeger SL, Spindler KP. A systematic review of anterior cruciate ligament reconstruction with autograft compared with allograft. J Bone Joint Surg. 2009;91(9):2242-2250. 6. Chen L, Cooley V, Rosenberg T. ACL reconstruction with hamstring tendon. Orthop Clin N Am. 2003;34(1):9-18.
Downloaded from fai.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
1021
Xu et al 7. Cole DW, Ginn TA, Chen GJ, et al. Cost comparison of anterior cruciate ligament reconstruction: autograft versus allograft. Arthroscopy. 2005;21(7):786-790. 8. Coughlin MJ, Schenck RC, Grebing BR, Treme G. Comprehensive reconstruction of the lateral ankle for chronic instability using a free gracilis graft. Foot Ankle Int. 2004;25(4):231-241. 9. Ellis SJ, Williams BR, Pavlov H, Deland J. Results of anatomic lateral ankle ligament reconstruction with tendon allograft. HSS J. 2011;7(2):134-140. 10. Foster TE, Wolfe BL, Ryan S, Silvestri L, Kaye EK. Does the graft source really matter in the outcome of patients undergoing anterior cruciate ligament reconstruction? An evaluation of autograft versus allograft reconstruction results: a systematic review. Am J Sports Med. 2010;38(1):189-199. 11. Fujii T, Kitaoka HB, Watanabe K, Luo Z-P, An K-N. Comparison of modified Broström and Evans procedures in simulated lateral ankle injury. Med Sci Sports Exerc. 2006;38(6):1025-1031. 12. Greis PE, Burks RT, Bachus K, Luker MG. The influence of tendon length and fit on the strength of a tendon-bone tunnel complex. A biomechanical and histologic study in the dog. Am J Sports Med. 2001;29(4):493-497. 13. Gulotta LV, Rodeo SA. Biology of autograft and allograft healing in anterior cruciate ligament reconstruction. Clin Sports Med. 2007;26(4):509-524. 14. Hua Y, Chen S, Jin Y, et al. Anatomical reconstruction of the lateral ligaments of the ankle with semitendinosus allograft. Int Orthop. 2012;36(10):2027-2031. 15. Jackson W, McGarvey W. Update on the treatment of chronic ankle instability and syndesmotic injuries. Curr Opin Orthop. 2006;17(2):97-102. 16. Jung H-G, Kim T-H, Park J-Y, Bae E-J. Anatomic reconstruction of the anterior talofibular and calcaneofibular ligaments using a semitendinosus tendon allograft and interference screws. Knee Surg Sports Traumatol Arthrosc. 2012;20(8):1432-1437. 17. Karlsson J, Andreasson GO. The effect of external ankle support in chronic lateral ankle joint instability: an electromyographic study. Am J Sports Med. 1992;20(3):257-261. 18. Karlsson J, Eriksson BI, Bergsten T, Rudholm O, Swärd L. Comparison of two anatomic reconstructions for chronic lateral instability of the ankle joint. Am J Sports Med. 1997;25(1):48-53. 19. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15(7):349-353. 20. MacAuley D. Ankle injuries: same joint, different sports. Med Sci Sports Exerc. 1999;31(7 suppl):S409. 21. Marsh JS, Daigneault JP, Polzhofer GK. Treatment of ankle instability in children and adolescents with a modified
Chrisman-Snook repair: a clinical and patient-based outcome study. J Pediatr Orthop. 2006;26(1):94-99. 22. Morrey B, Wiedeman G. Complications and long-term results of ankle arthrodeses following trauma. J Bone Joint Surg. 1980;62(5):777-784. 23. Organization WH. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. WHO technical report series. 854. Geneva, Switzerland: World Health Organization; 1995. 24. Oro FB, Sikka RS, Wolters B, et al. Autograft versus allograft: an economic cost comparison of anterior cruciate ligament reconstruction. Arthroscopy. 2011;27(9):1219-1225. 25. Poehling GG, Curl WW, Lee CA, et al. Analysis of outcomes of anterior cruciate ligament repair with 5-year follow-up: allograft versus autograft. Arthroscopy. 2005;21(7):774. e771-774. e715. 26. Prodromos C, Joyce B, Shi K. A meta-analysis of stability of autografts compared to allografts after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2007;15(7):851-856. 27. Reinhardt KR, Hetsroni I, Marx RG. Graft selection for anterior cruciate ligament reconstruction: a level I systematic review comparing failure rates and functional outcomes. Orthop Clin N Am. 2010;41(2):249-262. 28. Rice RS, Waterman BR, Lubowitz JH. Allograft versus autograft decision for anterior cruciate ligament reconstruction: an expected-value decision analysis evaluating hypothetical patients. Arthroscopy. 2012;28(4):539-547. 29. Richter J, Volz R, Immendörfer M, Schulz M. [Reconstruction of the lateral ankle ligaments with hamstring tendon autograft in patients with chronic ankle instability]. Oper Orthop Traumatol. 2012;24(1):50-60. 30. Schmidt R, Cordier E, Bertsch C, et al. Reconstruction of the lateral ligaments: do the anatomical procedures restore physiologic ankle kinematics? Foot Ankle Int. 2004;25(1):31-36. 31. Sun K, Tian S, Zhang J, et al. Anterior cruciate ligament reconstruction with BPTB autograft, irradiated versus nonirradiated allograft: a prospective randomized clinical study. Knee Surg Sports Traumatol Arthrosc. 2009;17(5):464-474. 32. Tohyama H, Beynnon BD, Pope MH, Haugh LD, Renström PA. Laxity and flexibility of the ankle following reconstruction with the Chrisman-Snook procedure. J Orthop Res. 1997;15(5):707-711. 33. Wang B, Xu X-Y. Minimally invasive reconstruction of lateral ligaments of the ankle using semitendinosus autograft. Foot Ankle Int. 2013;34(5):711-715. 34. Yamazaki S, Yasuda K, Tomita F, Minami A, Tohyama H. The effect of intraosseous graft length on tendon-bone healing in anterior cruciate ligament reconstruction using flexor tendon. Knee Surg Sports Traumatol Arthrosc. 2006;14(11): 1086-1093.
Downloaded from fai.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
research-article2014
FAIXXX10.1177/1071100714540145Foot & Ankle InternationalXu et al
Article
Minimally Invasive Reconstruction of the Lateral Ankle Ligaments Using Semitendinosus Autograft or Tendon Allograft
Foot & Ankle International® 2014, Vol. 35(10) 1015–1021 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100714540145 fai.sagepub.com
Xiangyang Xu, PhD1, Mu Hu, MD1, Jinhao Liu, MD1, Yuan Zhu, MD1, and Bibo Wang, MD1
Abstract Background: The purpose of the study was to retrospectively compare the therapeutic effect between semitendinosus autograft and tendon allograft for lateral ankle ligaments reconstruction. Methods: From September 2006 to June 2011, 68 patients (41 males, 27 females) with chronic ankle instability underwent anatomical reconstruction of the lateral ligaments using semitendinosus autograft (autograft group, 32 patients) or tendon allograft (allograft group, 36 patients) via a minimally invasive approach. All patients were followed up for at least 12 months. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score (AOFAS score) and stress tests were used to evaluate the clinical outcomes. Operation time, time to heal and complications were also recorded. Results: Compared with allograft group, the average operation time was significantly increased (85.5 ± 11.5 minutes vs 58.1 ± 10.2 minutes, P < .0001), but the mean time to heal was significantly shorter (11.2 ± 4.1 months vs 13.5 ± 5.2 months, P = .0458) in the autograft group. Although the mean AOFAS score was significantly increased at the final followup in the autograft group (95.1 ± 7.5 vs 62.3 ± 8.2, P = .0001) and allograft group (94.8 ± 5.5 vs 60.2 ± 8.4, P < .0001), no significant difference in AOFAS was found between these 2 groups. Similarly, there was no significant difference in talar tilt or shift between autograft and allograft groups. In addition, no patients complained of weakness or disability at the donor site in the autograft group, while incisional swelling was observed in 4 patients in the allograft group, which was resolved via dressing change, oral use of indomethacin or dexamethasone. Conclusion: Reconstruction of the lateral ankle ligaments using a semitendinosus tendon autograft and a minimally invasive approach was safe and effective for ankle instability with a relatively short time for healing and minimal donor site problems. Level of Evidence: Level III, comparative case series. Keywords: lateral ankle instability, ligament reconstruction, semitendinosus autograft, tendon allograft Acute ankle sprain is a common condition in which the ligaments of the ankle are completely or partially torn, accounting for approximately 15% of sports-related injuries.20 Bridgman et al3 reported that the incidence of ankle sprains is 60.9 per 10 000 in the United Kingdom, of which 14% are classified as severe (ie, 42 000 severe ankle sprains per year). Although most of the patients have satisfactory functional recovery after conservative treatment, some of them show mechanical instability and require operative intervention after several years.15 Currently, there are multiple operative techniques for chronic ankle instability, including anatomic repair (eg, Broström,2 Karlsson modified Broström,18 and Gould modified Broström4), nonanatomic reconstruction (eg, Chrisman-Snook21 and Evans procedures11), and anatomic
reconstruction. Anatomic repair uses the existing ligamentous tissues to restore the stability. If there is inadequate soft tissues due to repetitive ankle sprains or surgeries, reconstruction may be preferable to repair. Nonanatomic reconstruction stabilizes the ankle utilizing the peroneus brevis tendon, but does not reestablish the ankle kinematics, 1
Department of Orthopaedics, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China Xiangyang Xu and Mu Hu are co–first authors. Corresponding Author: Xiangyang Xu, PhD, Department of Orthopaedics, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Hao, RuiJin Er Rd, Shanghai 200025, China. Email: [email protected]
Downloaded from fai.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
1016
Foot & Ankle International 35(10)
Table 1. Comparison of Clinical Manifestation of Patients in Autologous and Allograft Groups. Comparability Clinical manifestation Gender (male/female) Average age (years) Injured ankle (left/right) Body mass index Time of initial injury to surgery (months) Operation outcome Operation time (minutes) Duration of fever (days) Time to heal (months) Follow-up Patients Duration
Autograft Group
Allograft Group
32 (19/13) 32.4 ± 2.4 14/18 28.7 ± 4.0 17.3 ± 2.1
36 (22/14) 33.2 ± 3.2 16/20 30.5 ± 5.2 19.1 ± 4.9
85.5 ± 11.5 2.5 ± 1.2 11.2 ± 4.1
58.1 ± 10.2 5.5 ± 1.5 13.5 ± 5.2
23 33.5 ± 6.7
26 28.5 ± 6.7
P Value .884 .2525 1.000 .1178 .058 .0000 .0000 .0458 .0122
possibly resulting in ankle stiffness.30,32 Subsequently, some have described an anatomic reconstruction using autograft33 or allograft tendon.14 Studies have demonstrated that anatomic reconstruction can not only significantly reduce both lateral ankle instability and talar tilt, but also lead to recovery of normal motion.29 The most common autograft tendons used are the extensor tendon of the fourth toe,1 plantaris,8 and semitendinosus.33 Meanwhile, allograft tendons mainly include tibialis anterior tendon allograft9 and semitendinosus tendon allograft.16 Previous studies have shown that there are no significant differences in short-term clinical outcomes between allograft and autograft tendon.5 Importantly, an allograft has the advantages of no donor site morbidity, shorter operation time and less postoperative pain compared with the autograft.25 Thus, allograft tendon has become a more common option. However, a recent expected-value decision analysis indicate patients’ aversion to allograft in general and decision to use autograft for anterior cruciate ligament reconstruction independent of expected outcomes.28 Therefore, it is necessary to develop a minimally invasive surgery for autograft tendon to reduce the tendon donor site problems, which was achieved in a previous study.33 In the present study, we aimed to further compare the clinical outcome of anatomical reconstructions of the lateral ankle ligaments using semitendinosus autograft or tendon allograft (Osteorad Ltd, Shanxi, China) via a minimally invasive approach retrospectively.
after we introduced the advantages and disadvantages of both methods. The autograft group included 19 males and 13 females with an average age of 32.4 ± 2.4 years, and the allograft group included 22 males and 14 females with an average age of 33.2 ± 3.2 years. The average time of initial injury to surgery was 17.3 ± 2.1 months in the autograft group and 19.1 ± 4.9 months in the allograft group. In the autograft group, 23 patients were followed an average of 33.5 ± 6.7 months, while 26 patients in the allograft group were followed an average of 28.5 ± 6.7 months (Table 1). The indications for surgery were (1) recurrent sprains more than twice within half a year; (2) severe ankle instability by a positive anterior drawer test (10 mm talar shift or 3 mm more than healthy side) or talar tilt (talar tilt > 9 degrees or 3 degrees more than healthy side);17 (3) failure of conservative treatments (rest, ice, compression, elevation, and support), or Broström and Gould surgeries (5 patients in autograft group and 7 patients in allograft group); and (4) obesity (body mass index > 25).23 All patients with the following surgery contraindications were excluded: (1) ankle infection, (2) fracture, and (3) ankle arthritis > grade 2 according to Morrey and Wiedeman classification.22 In addition, all patients underwent weight-bearing radiographs (anterior-posterior, mortise, and lateral views) of foot, gait analysis, and physical exam evaluation for injuries of anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL), such as swelling, congestion, and tenderness preoperatively.
Methods
Procedure
From September 2006 to June 2011, 68 patients having lateral ankle instability were treated via anatomical reconstruction of the lateral ligaments of the ankle in our hospital. These patients received the semitendinosus autograft (autograft group, 14 left/18 right) or tendon allograft (allograft group, 16 left/20 right) according to their financial situation
An arthroscopic-assisted minimally invasive surgery was performed on all patients as described in a previous study.33 After general or continual epidural anesthesia, the patients were placed supine and the knee of affected limb was flexed and rotated laterally. A tourniquet was routinely applied at the proximal thigh.
Downloaded from fai.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
1017
Xu et al
Figure 1. Stress test for examination of lateral ankle instability under arthroscopy. (A) Talar tilt test. (B) Anterior drawer test.
Figure 2. The semitendinosus tendon autograft was harvested with a minimally invasive technique. (A) Distal end of semitendinosus tendon. (B) Proximal end of semitendinosus tendon.
After verifying ankle instability by anterior drawer or talar tilt test under arthroscopy (Figure 1), the semitendinosus tendon was harvested from the ipsilateral affected limb via a 2-incision technique (Figure 2) in which the proximal incision was made at the most medial tendon 2 cm above the joint line and the distal incision was made 2 cm medial to the tibial tuberosity. After the 2 ends of the tendon were exposed, the semitendinosus tendon was isolated using a
specialized tendon stripper, released from the distal end, extracted from the proximal incision, and finally immersed in physiological saline until use after being woven with the 2-0 absorbable muscle-tendon suture (Johnson & Johnson Medical Ltd, Sommerville NJ, USA). The allograft ligament purchased from Osteorad Ltd (Shanxi, China) was trimmed to 14 cm (in length) × 8 mm (in width) × 1 mm (in thickness) after cryogenic processing and then woven
Downloaded from fai.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
1018
Foot & Ankle International 35(10)
through the 2-0 absorbable muscle-tendon suture (Johnson & Johnson Medical Ltd, Sommerville NJ, USA). At the recipient site of the ankle, 4 small incisions (5 mm in diameter) were made at the medial and lateral side of the fibular tip, the talar neck, and the middle portion of the calcaneus (Figure 3). Two guide wires were introduced transversely at the distal end of the fibula. Two holes were then drilled over the guide wire from each end to form a tunnel (4.5 mm in diameter, incline of 120 degrees). The prepared semitendinosus tendon autograft was introduced through the tunnel by a long eyelet needle. The ends of the tendon were then passed above the bone surface to the incisions at the talar neck and calcaneus. Guide wires were placed for positioning of talar and calcaneal tunnels under C-arm fluoroscopy. A 7 mm × 23 mm biodegradable inference screw (polyl-l-lactic acid, BioCryl®, DePuy Mitek, Raynham, MA) was used to fix the tendon graft in the talar neck and calcaneus. The location of interference screws was also detected under C-arm fluoroscopy.
Postoperative Management After operation, smoking was prohibited. The affected foot was immobilized in a valgus position and a weightfree manner using a U-shaped plaster. Antibiotics were routinely used for 24 hours after operation. Isometric dorsiflexion strengthening of the ankle was allowed to reduce stiffness at 3 days after operation. Four weeks after surgery, the cast was changed to an ankle orthosis and partial weight-bearing exercises were encouraged. Six weeks after the surgery, full weight-bearing exercises were permitted. The ankle orthosis was removed at 10 weeks after operation, and walking with a soft brace (Company OPED, Valley, Germany) was allowed. Jogging was resumed at 12 weeks after operation.
Clinical Evaluation The operative data between the groups were recorded and analyzed, including operation time (minutes), duration of any fever (>37°C, days), time to heal (could walk on uneven ground steadily in months), and complications. The outcome of operative treatment was evaluated using the clinical rating scale of the American Orthopaedic Foot and Ankle Society (AOFAS, 100 points total).19 Donor site morbidity was assessed by subjective sensation at the donor site area, range of motion of the knee and strength. Postoperative stress radiographs were taken using a TELOS stress device (TELOS, METAX, Germany) at 150 N.
Statistical Analysis Statistical analysis was performed using SPSS 13.0 software (Chicago, IL). The Wilcoxon and signed tests were
used for statistical analysis of pre- and postoperative AOFAS. The significance level was defined as P < .05.
Results Compared with the allograft group, the average operation time was significantly increased (85.5 ± 11.5 minutes vs 58.1 ± 10.2 minutes, P < .0001), but the fever days and time to heal were significantly shorter (2.5 ± 1.2 days vs 5.5 ± 1.5 days, P < .0001; 11.2 ± 4.1 months vs 13.5 ± 5.2 months, P = .0458) in the autograft group (Table 1). At the final follow-up, the mean AOFAS score in the autograft group was significantly increased compared with preoperation (95.1 ± 7.5 vs 62.3 ± 8.2, P < .0001), as well as the allograft group (94.8 ± 5.5 vs 60.2 ± 8.4, P < .0001) (Table 2). However, no significant difference in the AOFAS score was found between the 2 groups preoperatively and at the final follow-up. Three patients in the autograft group and 2 in the allograft group reported residual instability on uneven ground. One patient in the autograft group walked unsteadily in daily life. No patients complained of weakness or disability at the donor site. Compared with preoperation, the stress radiography showed a significant reduction of both talar tilt (from 14.0 ± 3.2 degrees to 3.8 ± 1.2 degrees) and shift (12.3 ± 3.2 mm to 4.6 ± 1.2 mm) at the final follow-up in the autograft group as well as the allograft group (talar tilt from 13.0 ± 3.5 degrees to 3.6 ± 1.4 degrees; talar shift from 11.5 ± 2.3 mm to 4.3 ± 1.5 mm) (Table 2). However, there was also no significant difference in talar tilt or shift between autograft and allograft groups. Despite the greater number of ever days and time to heal needed in the allograft group, no evidence of sterile effusion overlying the absorbable screws was detected. The incisions were normally healed in most patients due to only mild rejection using cryogenically preserved allograft. Incisional swelling lasted for 5 to 10 days in 4 patients, which resolved via dressing change, oral use of indomethacin, or dexamethasone. No incisional complications were noted in the autograft group. No patient required reoperation.
Discussion Although several studies have demonstrated no significant differences in clinical outcomes between allograft and autograft tendon for reconstruction of the lateral ankle ligaments, allograft reconstruction is significantly more expensive than autograft reconstruction24 and has the potential for disease transmission, limiting its acceptance for routine ankle reconstruction.26 Therefore, autograft tendon is still preferable for most patients. To reduce the disadvantages of autograft tendon (donor site morbidity), we described a minimally invasive approach for reconstruction
Downloaded from fai.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
1019
Xu et al
Figure 3. Anatomical anterior talofibular ligament (ATFL) and calcaneofibular ligament reconstruction by semitendinosus tendon autograft with a minimally invasive technique. (A) 4 small incisions (5 mm) at the lateral malleolus. (B) Tendon loaded on eyelet needle for passage of the graft traction suture and tendon through distal fibula. (C) Tendon with traction suture at both ends. Middle part of tendon is inside distal fibular tunnel. (D) Clamp 2 guides clamp 1 through the subcutaneous tunnel. Then clamp 1 holds traction suture and leads tendon through tunnel to talar neck. (E) Interference screw was used to fix 1 end of tendon to the talus to reconstruct ATFL. (F) The other end of tendon was introduced into body of calcaneus. (G) The foot was slightly everted while inserting the interference screw into the calcaneus to keep the tension on lateral ligament.
Downloaded from fai.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
1020
Foot & Ankle International 35(10)
Table 2. AOFAS Score, Talar Tilt, and Talar Shift at Preoperation and Final Follow-Up.
AOFAS score (point) Preoperatively Final follow-up Talar tilt (degrees) Preoperatively Final follow-up Talar shift Preoperatively Final follow-up
Autograft Group
Allograft Group
62.3 ± 8.2 95.1 ± 7.5
60.2 ± 8.4 94.8 ± 5.5
14.0 ± 3.2 3.8 ± 1.2
13.0 ± 3.5 3.6 ± 1.4
12.3 ± 3.2 4.6 ± 1.2
11.5 ± 2.3 4.3 ± 1.5
P Valuea .0000 .0000 .0000 .0000 .0000 .0000
a
Compared with preoperatively.
of the lateral ligaments of the ankle using a semitendinosus autograft.33 The semitendinosus tendon is relatively easy to harvest and it is larger in diameter and provides a stronger graft for simultaneous reconstruction of the ATFL and CFL.6 Previous studies have demonstrated minimal donor site morbidity using the semitendinosus tendon.27 As expected, our results showed that no patients complained of weakness or disability at the donor site. Consistent with previous literature,5,10 our clinical results also showed no significant differences in the AOFAS scores, talar tilt, and talar shift between autograft and allograft groups. In addition, because additional time was required for autograft graft preparation, the average operation time was significantly increased in the autograft group compared with allograft group. Thus, some scholars believe that the cost of the allograft itself appears to be offset by the increased operating room time and a greater likelihood of overnight hospitalization for autograft procedures.7 However, a recent expected-value decision analysis demonstrated patients’ aversion to allograft tissue in general.28 This may be attributed to more febrile days and time to heal in the allograft group. The longer fever may be associated with the host immune response to the allograft and the ability of tissue banks in our country to process allografts.31 The exact reason needs to be further studied. The different collagen content and mechanical strength of the allograft tendon from the native ankle ligaments contributed to the greater time to heal, which may influence patients’ quality of life and return to work.13 Yamazaki et al reported that an increase in the length of the bone tunnel was positively correlated with the quality and strength of the reconstruction.34 Minimizing the mismatch of diameters between graft and tunnel may tighten the fit of the graft in the tunnel and improve healing.12 In this study, a 4.5 mm drill was used to create a tunnel that could be widened to 7 mm with an approximate depth of 23 mm. A 7 mm × 23 mm biodegradable interference
screw was used to fix the tendon graft in the talar neck and calcaneus. Thus, the time to heal was shorter in the autograft group, and no major postoperative complications (talar neck fractures, osteolysis, or sterile drainage) occurred. This study had several limitations. The first was the retrospective nature of the study which contributed to the different follow-up times in 2 groups. Second, the follow-up time of both groups was relatively short so long term follow-up should be done to further evaluate their outcomes. Third, the sample size was small. In conclusion, we retrospectively analyzed the effectiveness of semitendinosus autograft and tendon allograft used for anatomic reconstruction of the lateral ligaments for chronic ankle instability. Combined with the minimally invasive surgery, the healing of the semitendinosus autograft was slightly faster than the tendon allograft and minimal donor site morbidity was observed. The clinical outcomes of the 2 grafts were both excellent, and no significant difference was identified. However, further multicenter study is still needed with a larger sample size and longer follow-up. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Ahn JH, Choy W-S, Kim H-Y. Reconstruction of the lateral ankle ligament with a long extensor tendon graft of the fourth toe. Am J Sports Med. 2011;39(3):637-644. 2. Bell SJ, Mologne TS, Sitler DF, Cox JS. Twenty-six-year results after Broström procedure for chronic lateral ankle instability. Am J Sports Med. 2006;34(6):975-978. 3. Bridgman S, Clement D, Downing A, et al. Population based epidemiology of ankle sprains attending accident and emergency units in the West Midlands of England, and a survey of UK practice for severe ankle sprains. Emerg Med J. 2003;20(6):508-510. 4. Brodsky AR, O’Malley MJ, Bohne WH, Deland JA, Kennedy JG. An analysis of outcome measures following the BroströmGould procedure for chronic lateral ankle instability. Foot Ankle Int. 2005;26(10):816-819. 5. Carey JL, Dunn WR, Dahm DL, Zeger SL, Spindler KP. A systematic review of anterior cruciate ligament reconstruction with autograft compared with allograft. J Bone Joint Surg. 2009;91(9):2242-2250. 6. Chen L, Cooley V, Rosenberg T. ACL reconstruction with hamstring tendon. Orthop Clin N Am. 2003;34(1):9-18.
Downloaded from fai.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
1021
Xu et al 7. Cole DW, Ginn TA, Chen GJ, et al. Cost comparison of anterior cruciate ligament reconstruction: autograft versus allograft. Arthroscopy. 2005;21(7):786-790. 8. Coughlin MJ, Schenck RC, Grebing BR, Treme G. Comprehensive reconstruction of the lateral ankle for chronic instability using a free gracilis graft. Foot Ankle Int. 2004;25(4):231-241. 9. Ellis SJ, Williams BR, Pavlov H, Deland J. Results of anatomic lateral ankle ligament reconstruction with tendon allograft. HSS J. 2011;7(2):134-140. 10. Foster TE, Wolfe BL, Ryan S, Silvestri L, Kaye EK. Does the graft source really matter in the outcome of patients undergoing anterior cruciate ligament reconstruction? An evaluation of autograft versus allograft reconstruction results: a systematic review. Am J Sports Med. 2010;38(1):189-199. 11. Fujii T, Kitaoka HB, Watanabe K, Luo Z-P, An K-N. Comparison of modified Broström and Evans procedures in simulated lateral ankle injury. Med Sci Sports Exerc. 2006;38(6):1025-1031. 12. Greis PE, Burks RT, Bachus K, Luker MG. The influence of tendon length and fit on the strength of a tendon-bone tunnel complex. A biomechanical and histologic study in the dog. Am J Sports Med. 2001;29(4):493-497. 13. Gulotta LV, Rodeo SA. Biology of autograft and allograft healing in anterior cruciate ligament reconstruction. Clin Sports Med. 2007;26(4):509-524. 14. Hua Y, Chen S, Jin Y, et al. Anatomical reconstruction of the lateral ligaments of the ankle with semitendinosus allograft. Int Orthop. 2012;36(10):2027-2031. 15. Jackson W, McGarvey W. Update on the treatment of chronic ankle instability and syndesmotic injuries. Curr Opin Orthop. 2006;17(2):97-102. 16. Jung H-G, Kim T-H, Park J-Y, Bae E-J. Anatomic reconstruction of the anterior talofibular and calcaneofibular ligaments using a semitendinosus tendon allograft and interference screws. Knee Surg Sports Traumatol Arthrosc. 2012;20(8):1432-1437. 17. Karlsson J, Andreasson GO. The effect of external ankle support in chronic lateral ankle joint instability: an electromyographic study. Am J Sports Med. 1992;20(3):257-261. 18. Karlsson J, Eriksson BI, Bergsten T, Rudholm O, Swärd L. Comparison of two anatomic reconstructions for chronic lateral instability of the ankle joint. Am J Sports Med. 1997;25(1):48-53. 19. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15(7):349-353. 20. MacAuley D. Ankle injuries: same joint, different sports. Med Sci Sports Exerc. 1999;31(7 suppl):S409. 21. Marsh JS, Daigneault JP, Polzhofer GK. Treatment of ankle instability in children and adolescents with a modified
Chrisman-Snook repair: a clinical and patient-based outcome study. J Pediatr Orthop. 2006;26(1):94-99. 22. Morrey B, Wiedeman G. Complications and long-term results of ankle arthrodeses following trauma. J Bone Joint Surg. 1980;62(5):777-784. 23. Organization WH. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. WHO technical report series. 854. Geneva, Switzerland: World Health Organization; 1995. 24. Oro FB, Sikka RS, Wolters B, et al. Autograft versus allograft: an economic cost comparison of anterior cruciate ligament reconstruction. Arthroscopy. 2011;27(9):1219-1225. 25. Poehling GG, Curl WW, Lee CA, et al. Analysis of outcomes of anterior cruciate ligament repair with 5-year follow-up: allograft versus autograft. Arthroscopy. 2005;21(7):774. e771-774. e715. 26. Prodromos C, Joyce B, Shi K. A meta-analysis of stability of autografts compared to allografts after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2007;15(7):851-856. 27. Reinhardt KR, Hetsroni I, Marx RG. Graft selection for anterior cruciate ligament reconstruction: a level I systematic review comparing failure rates and functional outcomes. Orthop Clin N Am. 2010;41(2):249-262. 28. Rice RS, Waterman BR, Lubowitz JH. Allograft versus autograft decision for anterior cruciate ligament reconstruction: an expected-value decision analysis evaluating hypothetical patients. Arthroscopy. 2012;28(4):539-547. 29. Richter J, Volz R, Immendörfer M, Schulz M. [Reconstruction of the lateral ankle ligaments with hamstring tendon autograft in patients with chronic ankle instability]. Oper Orthop Traumatol. 2012;24(1):50-60. 30. Schmidt R, Cordier E, Bertsch C, et al. Reconstruction of the lateral ligaments: do the anatomical procedures restore physiologic ankle kinematics? Foot Ankle Int. 2004;25(1):31-36. 31. Sun K, Tian S, Zhang J, et al. Anterior cruciate ligament reconstruction with BPTB autograft, irradiated versus nonirradiated allograft: a prospective randomized clinical study. Knee Surg Sports Traumatol Arthrosc. 2009;17(5):464-474. 32. Tohyama H, Beynnon BD, Pope MH, Haugh LD, Renström PA. Laxity and flexibility of the ankle following reconstruction with the Chrisman-Snook procedure. J Orthop Res. 1997;15(5):707-711. 33. Wang B, Xu X-Y. Minimally invasive reconstruction of lateral ligaments of the ankle using semitendinosus autograft. Foot Ankle Int. 2013;34(5):711-715. 34. Yamazaki S, Yasuda K, Tomita F, Minami A, Tohyama H. The effect of intraosseous graft length on tendon-bone healing in anterior cruciate ligament reconstruction using flexor tendon. Knee Surg Sports Traumatol Arthrosc. 2006;14(11): 1086-1093.
Downloaded from fai.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
