Many authors have affirmed the value of the Watson-Jones tenodesis for the treatment of chronic lateral instability of the ankle on the basis of the short-term results6,12,20,36,37. Van der Rijt and Evans, in 1984, were the first investigators, to our knowledge, to report unsatisfactory long-term results after a Watson-Jones tenodesis34. In their series of nine patients, who were followed for a mean of twenty-two years, the early, favorable results were found to have deteriorated seven to ten years after the operation. A weakness of that report was the small number of patients. Few papers concerning the results of the Watson-Jones tenodesis subsequently were published. In 1994, Hoy and Henderson reported that they had not found any association between the results of the procedure in thirty patients (thirty-two ankles) and the duration of follow-up (mean, less than five years)13. We do not believe that there have been any reports in which both the number of patients and the mean duration of follow-up were sufficient to allow evaluation of the results of this procedure.
Many different rating systems for evaluation of the results of treatment of instability of the ankle have been used in the studies reported in the literature8,14,15,28. In the current study, we used both the ankle-hindfoot scale proposed by the American Orthopaedic Foot and Ankle Society in 199415 and the subjective grading system reported by Good et al. in 19758. The ankle-hindfoot scale was not intended specifically for the evaluation of instability of the ligaments, but it is conventional and simple to use. The scale consists partially of objective criteria, including motion of the hindfoot. The classic method of rating that was proposed by Good et al. is simpler and is useful for the assessment of patients who are followed with telephone interviews or questionnaires without direct examination. With use of these two rating systems, the results of our study can be compared with data from other studies.
Before beginning this long-term follow-up study, we did not expect such satisfactory results; a high proportion (thirty) of the thirty-four ankles in our series had an excellent or good outcome. This rate is comparable with the short-term results that have been reported after an original or modified Watson-Jones tenodesis: eighteen (90 percent) of twenty ankles in the series of Gillespie and Boucher6, forty-six (94 percent) of forty-nine ankles in the series of Zenni et al.37, and seventeen (81 percent) of twenty-one ankles in the series of Hedeboe and Johannsen12 had a good or excellent result.
Kjærsgaard-Andersen et al. found that the Watson-Jones ankle tenodesis did not restore the normal kinematics of the hindfoot16, and Liu and Baker, in a study of cadavera, reported that the modified Broström procedure produced greater mechanical restraints than did the Watson-Jones procedure19. Liu and Baker stated that the first limb of the tenodesis, from the fifth metatarsal to the fibula, is perpendicular to the anatomical direction of the calcaneofibular ligament and therefore does not play the role of a ligament. However, the mean talar tilt angle in their patients improved after a Watson-Jones tenodesis, which suggests that the first limb of the tenodesis may help to prevent tilting of the talus. Also, the second and third limbs of the tenodesis, between the neck of the talus and the fibula, are parallel to the anterior talofibular ligament. In the current series, we performed the operation in such a way that the second and third limbs of the tenodesis were located parallel and close together, thereby restoring the anterior talofibular ligament. Nevertheless, sagittal mechanical instability was not restored as well, possibly because of elongation or loosening of the tendon graft over the long term.
We found no relationship between the score on the ankle-hindfoot scale of the American Orthopaedic Foot and Ankle Society and the duration of follow-up, and we detected no deterioration of the results. However, significant correlations between the score and the age of the patient were found. Problems with the joints in the lower extremity and the spine increase with age, and walking ability decreases; these factors affect the results. In some of our patients, the score on the ankle-hindfoot scale was in fact affected by osteoarthrosis or an injury of a knee ligament. The use of this type of scale, which contains a subsection related to the patient's ability to walk, makes it difficult to avoid the influence of other diseases of the joints or abnormal neurological conditions.
The mean age of our patients at the time of the operation was almost the same as that of patients in other reports on the results of the Watson-Jones tenodesis. However, at the time of the latest follow-up, ten to eighteen years after the operation, the mean age of our patients was forty-four years, which was greater than the mean age of patients in other reports except that of Van der Rijt and Evans; their nine patients had a mean age of fifty-four years at the time of the latest follow-up, and six had an unsatisfactory outcome34. Those authors thought that the poor results were due to the instability of the ankle; however, we believe that they may have been related to the older age of their patients at the time of follow-up. We do not know why their results differed from ours, but there may have been some minor differences in the details of the operative procedure.
Despite the good clinical results, atrophy of the calf muscles was found in our patients long after the operation. The mean decrease in the circumference of the calf was similar to that reported by Lucht et al.20. We do not know whether the main cause of this decrease is general disuse atrophy of the leg or selected atrophy of the peroneus brevis muscle, which is sacrificed at the time of the operation. Although weakness of the peroneal muscles was not detected with the manual test, eight of our patients described mild weakness of these muscles after walking for a long distance or after strenuous activity. St. Pierre et al. reported that loss of the peroneus brevis tendon did not appear to result in a marked loss of eversion strength and power32.
Minor exostoses, seen in ten of our patients before the operation, represented an early stage of osteoarthrosis. The number of patients who had this finding nearly doubled postoperatively, but no patient had narrowing of the joint space of the affected ankle at the time of the latest follow-up. The increase in the number of patients who had a minor exostosis may have been due to the instability of the ankle even after the operation. There have been a few reports on these exostoses after other operative techniques17,22. Korkala et al.17 reported osteophytes of the ankle after an Evans procedure but found no relationship between the subjective outcome and the presence of osteophytes.
Michelson and Hutchins reported the presence of mechanoreceptors in the lateral ligament of the ankle21. It has not been determined whether these mechanoreceptors can be restored in the repaired or reconstructed ligaments. If the mechanoreceptors are not reproduced in the reconstructed ligaments, minor functional instability due to their absence may cause exostoses.
In the current series of Watson-Jones tenodeses, complications were found in six (18 percent) of thirty-four ankles. This rate is similar to those reported by Van der Rijt and Evans34 (two of nine ankles) and Younes et al.36 (two of ten ankles). Snook et al. reported a higher rate of complications (fourteen of forty-eight ankles) after the Chrisman-Snook operation, although they emphasized that numbness persisted in only four patients30. The high rate of complications associated with these types of operations is due to nerve lesions, caused by the long incision that is needed to obtain the peroneus brevis tendon, which is close to the sural nerve.
In contrast, an anatomical reconstruction such as the modified Broström repair is less invasive than a tenodesis or a reconstruction with use of autogenous tendon graft. Low rates of complications have been reported after anatomical repair and reinforcement operations. Karlsson et al.14 reported one complication (3 percent) in thirty ankles; Gould et al.9, one complication (2 percent) in fifty ankles; and Hamilton et al.11, no major complications in twenty-eight ankles. These low rates of complications and the small operative scars are encouraging, and the recent trend has been toward delayed primary repair or augmented repair. The ideal reconstruction would restore the natural or original anatomy. In order to achieve an anatomical reconstruction, many options must be available to the surgeon because the condition of the injured ligaments varies among patients. Fortunately, the development of suture anchor systems has made anatomical reconstruction easier to perform.
In the near future, reconstruction with use of the peroneus brevis tendon may be replaced by anatomical restoration. If there are no differences in the long-term results between these procedures, we would choose anatomical reconstruction because it is associated with fewer complications and necessitates less extensive exploration. However, the long-term results of anatomical restoration (those seen after a mean duration of more than ten years) have not yet been reported, to our knowledge.
In summary, the long-term results of the Watson-Jones procedure have been reported by several authors, but we are not aware of any previous study in which a sufficient number of patients were followed for a long period. We found that the results of a modified Watson-Jones tenodesis were good; did not deteriorate over the long term; and, although not ideal, were much better than we had expected.
NOTE: The authors thank Hiroshi Yajima, M.D., Hiroshi Iwamoto, M.D., Shigeru Mizumoto, M.D., and Takanori Takaoka, M.D., for their assistance with this study.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
1. Anderson, K. J.; LeCocq, J. F.; and LeCocq, E. A.: Recurrent anterior subluxation of the ankle joint. A report of two cases and an experimental study. J. Bone and Joint Surg.
, 34-A: 853-860, Oct. 1952.
2. Broström, L.: Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures. Acta Chir. Scandinavica
, 132: 551-565, 1966.
3. Chrisman, O. D., and Snook, G. A.: Reconstruction of lateral ligament tears of the ankle. An experimental study and clinical evaluation of seven patients treated by a new modification of the Elmslie procedure. J. Bone and Joint Surg.
, 51-A: 904-912, July 1969.
4. Elmslie, R. C.: Recurrent subluxation of the ankle-joint. Ann. Surg.
, 100: 364-367, 1934.
5. Evans, D. L.: Recurrent instability of the ankle—a method of surgical treatment. Proc. Roy. Soc. Med., 46: 343-344, 1953.
6. Gillespie, H. S., and Boucher, P.: Watson-Jones repair of lateral instability of the ankle. J. Bone and Joint Surg.
, 53-A: 920-924, July 1971.
7. Glas, E.; Paar, O.; Smasal, V.; and Bernett, P.: Die Periostlappenplastik (PLP) am Auβenbandapparat des oberen Sprunggelenkes. Unfallchirurg
, 88: 219-222, 1985.
8. Good, C. J.; Jones, M. A.; and Livingstone, B. N.: Reconstruction of the lateral ligament of the ankle. Injury
, 7: 63-65, 1975.
9. Gould, N.; Seligson, D.; and Gassman, J.: Early and late repair of lateral ligament of the ankle. Foot and Ankle
, 1: 84-89, 1980.
10. Gould, N.: Repair of lateral ligament of ankle. Foot and Ankle
, 8: 55-58, 1987.
11. Hamilton, W. G.; Thompson, F. M.; and Snow, S. W.: The modified Broström procedure for lateral ankle instability. Foot and Ankle
, 14: 1-7, 1993.
12. Hedeboe, J., and Johannsen, A.: Recurrent instability of the ankle joint. Surgical repair by the Watson-Jones method. Acta Orthop. Scandinavica
, 50: 337-340, 1979.
13. Hoy, G. A., and Henderson, I. J. P.: Results of Watson-Jones ankle reconstruction for instability. The influence of articular damage. J. Bone and Joint Surg.
, 76-B(4): 610-613, 1994.
14. Karlsson, J.; Eriksson, B. I.; Bergsten, T.; Rundholm, O.; and Sward, L.: Comparison of two anatomic reconstructions for chronic lateral instability of the ankle joint. Am. J. Sports Med.
, 25: 48-53, 1997.
15. Kitaoka, H. B.; Alexander, I. J.; Adelaar, R. S.; Nunley, J. A.; Myerson, M. S.; and Sanders, M.: Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot and Ankle
, 15: 349-353, 1994.
16. Kjærsgaard-Andersen, P.; Sojbjerg, J. O.; Wethelund, J. O.; Helmig, P.; and Madsen, F.: Watson-Jones tenodesis for ankle instability. A mechanical analysis in amputation specimens. Acta Orthop. Scandinavica
, 60: 477-480, 1989.
17. Korkala, O.; Tanskanen, P.; Mäkijärvi, J.; Sorvali, T.; Ylikoski, M.; and Haapala, J.: Long-term results of the Evans procedure for lateral instability of the ankle. J. Bone and Joint Surg.
, 73-B(1): 96-99, 1991.
18. Landeros, O.; Frost, H. M.; and Higgins, C. C.: Post-traumatic anterior ankle instability. Clin. Orthop.
, 56: 169-178, 1968.
19. Liu, S. H., and Baker, C. L.: Comparison of lateral ligamentous reconstruction procedures. Am. J. Sports Med.
, 22: 313-317, 1994.
20. Lucht, U.; Vang, P. S.; and Termansen, N. B.: Lateral ligament reconstruction of the ankle with a modified Watson-Jones operation. Acta Orthop. Scandinavica
, 52: 363-366, 1981.
21. Michelson, J. D., and Hutchins, C.: Mechanoreceptors in human ankle ligaments. J. Bone and Joint Surg.
, 77-B(2): 219-224, 1995.
22. Ottosson, L.: Lateral instability of the ankle treated by a modified Evans procedure. Acta Orthop. Scandinavica
, 49: 302-305, 1978.
23. Reichelt, A., and Weyrauch, H. J.: Beitrag zur operativen Behandlung von Bandverletzungen des oberen Sprunggelenkes. Unfallheilkunde
, 85: 427-430, 1982.
24. Riegler, H. F.: Reconstruction for lateral instability of the ankle. J. Bone and Joint Surg.
, 66-A: 336-339, March 1984.
25. Rubin, G., and Witten, M.: The talar-tilt angle and the fibular collateral ligaments. A method for the determination of talar tilt. J. Bone and Joint Surg.
, 42-A: 311-326, March 1960.
26. Savastano, A. A., and Lowe, E. B., Jr.: Ankle sprains: surgical treatment for recurrent sprains. Report of 10 patients treated with the Chrisman-Snook modification of the Elmslie procedure. Am. J. Sports Med.
, 8: 208-211, 1980.
27. Sefton, G. K.; George, J.; Fitton, J. M.; and McMullen, H.: Reconstruction of the anterior talofibular ligament for the treatment of the unstable ankle. J. Bone and Joint Surg.
, 61-B(3): 352-354, 1979.
28. Seligson, D.; Gassman, J.; and Pope, M.: Ankle instability: evaluation of the lateral ligaments. Am. J. Sports Med.
, 8: 39-42, 1980.
29. Sjølin S. U.; Dons-Jensen, H.; and Simonsen, O.: Reinforced anatomical reconstruction of the anterior talofibular ligament in chronic anterolateral instability using a periosteal flap. Foot and Ankle
, 12: 15-18, 1991.
30. Snook, G. A.; Chrisman, O. D.; and Wilson, T. C.: Long-term results of the Chrisman-Snook operation for reconstruction of the lateral ligaments of the ankle. J. Bone and Joint Surg.
, 67-A: 1-7, Jan. 1985.
31. Solheim, L. F.; Denstad, T. F.; and Roaas, A.: Chronic lateral instability of the ankle. A method of reconstruction using the Achilles tendon. Acta Orthop. Scandinavica
, 51: 193-196, 1980.
32. St. Pierre, R. K.; Andrews, L.; Allman, F., Jr.; and Fleming, L. L.: The Cybex II evaluation of lateral ankle ligamentous reconstructions. Am. J. Sports Med.
, 12: 52-56, 1984.
33. Vainionpää, S.; Kirves, P.; and Laike, E.: Lateral instability of the ankle and results when treated by the Evans procedure. Am. J. Sports Med.
, 8: 437-439, 1980.
34. Van der Rijt, A. J., and Evans, G. A.: The long-term results of Watson-Jones tenodesis. J. Bone and Joint Surg.
, 66-B(3): 371-375, 1984.
35. Watson-Jones, R.: Fractures and Joint Injuries. Ed. 4, vol. 2, pp. 817-830. Baltimore, Williams and Wilkins, 1960.
36. Younes, C.; Fowles, J. V.; Fallaha, M.; and Antoun, R.: Long-term results of surgical reconstruction for chronic lateral instability of the ankle: comparison of Watson-Jones and Evans techniques. J. Trauma
, 28: 1330-1334, 1988.
37. Zenni, E. J., Jr.; Grefer, M.; Krieg, J. K.; Lambert, M. B.; and Florez, R.: Lateral ligamentous instability of the ankle: a method of surgical reconstruction by a modified Watson-Jones technique. Am. J. Sports Med.
, 5: 78-83, 1977.
38. Zwipp, H., and Tscherne, H.: Zur Behandlung der chronischen antero-lateralen Instabilität des oberen Sprunggelenkes: direkte Bandrekonstruktion—Periostlappenplastik—Tenodese. Unfallheilkunde
, 87: 405-415, 1984.