Injury to the lateral ligaments account for 15% to 25% of all muskuloskeletal injuries and as many as 50% of injuries in sports that require cutting and jumping. 1,42,50 Most low-grade injuries probably never are evaluated by a physician and either treated in the training room or not at all. Patients with higher-grade injuries usually have significant pain and swelling and are more likely to seek medical care acutely or shortly after the injury. Twenty to 40% of patients with severe sprains will have continued problems with pain and instability. 1,3,5,9,10,18,21,24,25,38,39,47
Controversy continues to develop over the best treatment for Grade III ankle sprains with complete disruption of the lateral ankle ligaments. Comparative studies of functional treatment versus acute surgical repair of the ruptured ligaments have been done with some advocating better results with surgical repair, and others finding no difference in final outcome between surgical and functional treatment. 2,10,22,24,29,43,51,53,57,58,65
More than 50 surgical procedures have been described for the treatment of chronic lateral ankle instability, 7,8,56 most of which focus on the reconstruction of mechanical restraints to talar instability. Anatomic reconstruction attempts to either directly repair the injured ligaments or replace them with local or transferred tissue. Anatomic reconstruction of the injured ligaments restores normal resistance to anterior translation and inversion without restriction of subtalar or ankle motion. 3,18 Direct repair of the ligaments as described by Brostrom 11 is not always possible because attenuation of the tissue may occur with chronic repetitive trauma. Other techniques have been developed to achieve more reproducible stability by either directly advancing the ligaments into bony troughs in the fibula, 31,37,38,48,71,74 augmenting the repair with local tissues, 28,30,71 or anatomic tenodesis procedures that completely replace the ligaments with local grafts from the peroneus brevis, peroneus longus, accessory peroneal, peroneus tertius, fibular periosteum or distant grafts from the plantaris, palmaris longus or fascia lata. 3,4,12,17,18,20,40,54,63,64,66–68,74
Nonanatomic reconstructions also have been used extensively in the treatment of lateral ankle instability and function to control talar instability by applying restraint to inversion and anterior translation. These procedures do not attempt to restore local anatomy, but create restraints to abnormal motion by positioning graft material perpendicular to the perceived instability. The most frequently reported nonanatomic reconstructions are modifications of those described by Watson-Jones, 77 Chrisman and Snook, 14 and Evans. 21 These tenodesis procedures have been shown to dramatically alter the biomechanics of the ankle and subtalar joints, and significantly alter the normal plantar loading of the hindfoot, midfoot, and forefoot. 3,6–8,18,41,61,63 Functional instability of the ankle results from disruption of normal arthrokinetic reflexes attributable to injured ankle ligaments and loss of proprioception. 15,24,26,61 Surgical treatment of lateral ankle instability through ligament reconstruction, tenodesis, or muscle transfer improves proprioception and improves functional stability above the mechanical constraints of the reconstruction. 6,25,30,34,44,52,75
Success of surgery in selected individuals is reported to be high with several studies reporting good and excellent results between 80% and 95% regardless of the type of surgical procedure. 16,56 Surgical complications are infrequent but present problems when encountered. The summary data presented in Table 1, include only studies in which complications were reported. Studies in which the authors did not comment on the presence or absence of surgical complications were excluded from this table and there may have been significant variation on what was considered noteworthy; therefore, the reader is cautioned to interpret the summary numbers cautiously. Complications of surgery can occur early in the postoperative period and are directly related to surgical technique, patient compliance, and postoperative protocol. Early complications usually are related to wound healing, infection, or injury to the cutaneous nerves of the ankle. Recurrent instability can be a difficult problem to address and can result from reinjury, but is more commonly associated with selection of a procedure that does not adequately recreate the mechanical restraints required for stability. Patients with unusual conditions such as ligamentous laxity and cavovarus foot deformity are at high risk for having recurrence if these underlying conditions are not addressed at the primary procedure. A common reason for residual disability, particularly with tenodesis procedures, is loss of motion of the ankle and subtalar joints. Long-term complications of degenerative joint disease of the ankle and subtalar joint are well-recognized, although it is unclear whether these are sequelae of repetitive trauma from preoperative instability or attibutable to abnormal joint loading after reconstruction. The purpose of the current study is to review reported surgical complications and to suggest treatment options when these complications are encountered.
Wound and Nerve Complications
Wound complications after lateral ankle ligament reconstruction are common. In reviewing series of surgical treatment of ankle instability, there were 41 reports of superficial or significant wound healing problems in 1516 cases (Table 1). Almost all wound complications were superficial and responded to local wound care. Hennrikus et al 31 reported higher wound complication rates with the Chrisman-Snook procedure than the Brostrom procedure including two patients with wound dehiscence. The use of carbon fiber to reconstruct the ligaments of the ankle was associated with significant wound healing problems and infection. Freedman et al 23 reported five infections with carbon fiber reconstruction of the anterior talofibular ligament and posterior talofibular ligament. The foreign material was removed in all infected cases and a revision was done in three cases. Septic arthritis 33 and calcaneal osteomyelits 59 have been reported, but deep infections are rare. Patients with these complications require surgical debridement and thorough irrigation to remove infected hematoma and necrotic tissue. Culture-specific antibiotics are important to eradicate the infectious process. Attempts should be made to retain the ligamentous construct, but if foreign material or allograft were used, staged reconstruction after radical debridement may be indicated.
Nerve dysfunction after ankle ligament reconstruction has been reported to be as high as 52%6,32 and may range in severity from a subjective feeling of hyposensibility to severe disabling pain from neuroma or entrapment. 70 In reviewing reports of surgery for acute or chronic lateral ankle injury, an overall incidence of 6.2% (94 of 1516) of reported nerve complications including sensory deficits of the dorsal lateral foot and toes and painful neuromas requiring surgical exploration or excision are seen (Table 1). The sural nerve seems to be at greater risk with peroneal tenodesis procedures, and the superficial peroneal nerve is at greater risk with acute or delayed repair of the ligaments. Other reported perioperative complications include reflex sympathetic dystrophy and other neurogenic pain syndromes, deep venous thrombosis, and pulmonary embolus. 4,22,43,46,66,67,71
Recurrent instability after ankle reconstruction is reported with every type of repair including acute and delayed primary repairs and in anatomic and nonanatomic tenodesis procedures. Failure of the reconstruction to correct instability may be classified into four groups. The procedure may fail because of inadequate reconstruction of the anatomic constraints, the patient may continue to have functional instability despite solid ankle ligament reconstruction, reinjury to the ankle can occur, or a predisposing factor that was overlooked during the initial surgery may be present.
Nonanatomic Tenodesis Procedures
The failure of initial surgery to establish mechanical stability is dependent on the type of procedure selected, the plane of mechanical instability being addressed, and the ability of the surgeon to technically establish the goals of the procedure. In addressing postoperative instability after nonanatomic tenodesis procedures such as the Watson-Jones, Evans, and Chrisman-Snook procedures, it is helpful to consider anatomic and biomechanical data, because restoration of normal mechanical restraints is not achieved with these procedures. 3,18,62
Subjective instability after the Watson-Jones tenodesis has been reported to be from 3% to 66%. 4,6,12,13,27,32,49,76 This wide range probably results from different evaluation parameters, but some authors think that the procedure is able to accomplish good long-term stability. 27,49 Others have reported continued instability in talar tilt testing. 18 Radiographic instability, however, does not always correlate with a poor functional outcome. 13,33 In a review of nine patients with an average 22-year followup, Van der Rijt and Evans 76 noted a high rate of subjective instability, and deterioration of talar tilt and anterior drawer stability with time.
Serial sectioning of the anterior talofibular ligament and calcaneofibular ligament was done by Bahr et al 3 and the patterns of instability were compared with the Watson-Jones tenodesis. The Watson-Jones reconstruction restored stability in all planes at the tibiotalar joint but did not restore stability to the subtalar joint. The posterior limb of the graft in the Watson-Jones reconstruction was under significantly greater strain during loaded supination testing and joint motion was restricted compared with the normal ankle in plantar flexion, supination, and internal rotation. This may explain why the subjective and objective stability of this procedure deteriorate with time. 13,76 In a cadaver model, Colville et al 18 found that Watson-Jones reconstruction controlled anterior drawer testing and internal rotation, but that talar tilt was not controlled and subtalar motion was diminished. Other studies confirmed the inability of the Watson-Jones procedure to restore normal joint kinematics. 41,62
The Evans tenodesis procedure has been used extensively for correction of lateral ankle instability. Subjective instability after this technique is 9% to 83%. 5,7,13,32,36,55,60,74 In a cadaver model, Colville et al 18 reported the procedure failed to correct abnormal displacement of the talus with anterior drawer testing and talar tilt testing, and failed to correct internal rotation when compared with ankles with intact ligaments. Rosenbaum et al 62 reported marked diminution of subtalar motion and showed that ankle stability with this procedure is achieved by reducing subtalar movement to a nonphysiologic level. In clinical studies, several authors observed objective instability and fair or poor results correlated highly with continued clinical instability. 36,55 Others found no correlation between objective instability and functional results. 5,8,13 In studies with an average followup less than 10 years, the average good or excellent clinical results was 92%, 7,8,32 but three studies reviewed with greater than 10 years followup averaged only 71% good or excellent results, 5,36,55 suggesting that results deteriorate with time.
The Chrisman-Snook procedure has undergone many modifications, and has a high rate of reported patient satisfaction. Of the nonanatomic tenodesis procedures, the Chrisman-Snook procedure had the lowest percentage of postoperative subjective instability, ranging from 0% to 18%. 13,14,31,32,72–74 The procedure achieves better stability in talar tilt because of a direct reconstruction of the calcaneofibular ligament by attaching it’s posterior limb to the calcaneus. 14 In a cadaver model, Colville et al 18 showed it to be effective in limiting talar tilt, but allowed continued anterior translation and internal rotation. Modifications to the anterior limb align the graft anatomically to address this problem. 73
Anatomic Tenodesis Procedures
Anatomic reconstruction of the lateral ligaments using either a tenodesis or free tendon graft essentially is a modification of the original procedure described by Elmslie. 20 These procedures attempt to approximate the anatomic origins and insertions of the anterior talofibular ligament and calcaneofibular ligament. The correct insertion point is identified by dissecting and identifying the torn or attenuated ligament and tracing it to its attachment point on the calcaneus or talus. Anatomic reconstruction controls rotational stability, talar tilt and anterior subluxation, while preserving normal joint kinematics. 3,18,62 Clinical studies of anatomic tenodesis procedures that noted low subjective instability (0% to 3%) had clinically good or excellent outcomes in 91% to 100% of patients. 54,67,68
Delayed Primary Repair of Ligaments
Brostrom 11 first described direct repair of chronically torn ankle ligaments in patients with instability. Bahr et al 3 showed that repair of the anterior talofibular ligament and calcaneofibular ligament restored normal ankle motion and control of talar tilt, although anterior translation was not controlled as well as with tenodesis procedures. Attenuation of the anterior talofibular ligament and calcaneofibular ligament may occur, particularly in patients with long-standing instability, 37 but local augmentation with retinacular or periosteal flaps has yielded long-term results that are similar to other, more extensive tenodesis or reconstructive procedures. 28,30,38,64,71 Subjective residual instability have been reported to be 5% to 12%, 31,37,38,47 and good or excellent results have been reported to be 75% to 96%. 30,31,37,38,47
Traumatic Recurrence of Instability
In the reviewed series, no acute or delayed procedure can be described as being more protective or at risk for recurrent sprains. After acute repair, Agoropoulos et al 2 described two recurrent severe sprains in athletes who were treated conservatively and did not require additional surgery. Povacz et al 58 also reported that after 73 acute ligament repairs, 20 patients had additional ankle sprains in the 2-year followup period, although none required additional surgical treatment. A severe sprain after delayed ligament reconstruction was reported by Hennrikus et al. 31 The patient did not respond well to conservative treatment and subsequently was treated with the Chrisman-Snook procedure.
Significant ankle trauma can cause failure of previously successful tenodesis procedures. In two of the three patients with unsuccessful results after undergoing the Evans procedure, Barnum et al 5 observed that successful initial treatment had been complicated by reinjury of the ankle causing functional instability. Larsen 45 observed rupture of an Evans tenodesis after a patient sustained a fall of 2 m. Snook et al 73 reported three severe sprains after Chrisman-Snook procedures that caused disruption of the tenodesis and recurrence of instability. Two patients were treated with cast immobilization and had return of significant ankle instability that did not respond to therapy. The patients were offered revision reconstruction but declined. The third case was complex. The patient had ligamentous laxity and had multiple reconstructions of the medial and lateral ankle ligaments. She did poorly after revision surgery. In a series reported by Brunner and Gaechter, 12 rupture of the graft occurred in two patients after Watson-Jones tenodesis, and the patients required revision fixation. Sammarco and DiRaimondo 67 and Sammarco and Carrasquillo 66 described four cases where the tendon graft was ruptured with significant trauma. The graft in one patient who jumped from a 5 ft platform onto a curb healed uneventfully with conservative treatment. 66 One patient who stepped into a hole, 67 and two with high impact sports injuries 67 were treated with revision anatomic reconstructions. These patients had subsequent successful outcomes.
Ligamentous laxity has been reported by several authors to be associated with recurrent instability after ankle ligament reconstruction. In two large series, Karlsson et al 35,38 reported that direct repair of the ligaments in patients with generalized joint hypermobility presents a significant risk for mechanical failure of the procedure. Connective tissue disease such as Ehlers-Danlos or Marfan’s syndrome may make autogenous tissue unsuitable. Schon did successful ankle ligament reconstruction using hamstring allograft and bone anchors in a patient with Ehlers-Danlos syndrome after a failed Chrisman-Snook procedure (Personal oral communication, Lew C. Schon, MD, 1999), whereas other authors have suggested the use of carbon fiber material in such cases. 7,23 Colville 16 suggests that the primary procedure should limit subtalar motion if generalized ligamentous laxity is present.
Cavovarus deformity of the foot also has been reported to be a predisposing factor to the development of ankle instability. 46 With the heel in varus, the weightbearing axis is medialized in relation to the ankle, placing higher demands on the lateral ligament complex. Sammarco and Taylor 69 observed lateral ankle instability as a presenting complaint in 24% of patients reviewed for surgical correction of cavovarus foot deformity. Correction of the underlying deformity through calcaneal and metatarsal osteotomies resolved the instability in these patients and ligament reconstruction was not necessary. Brunner and Gaechter 12 reported varus deformity of the calcaneus as a reason for recurrence of instability after Watson-Jones tenodesis. Brostrom 10 reported failure of lateral ligament repair in a patient with Charcot-Marie-Tooth disease who had cavovarus foot deformity and peroneal weakness.
Treatment of Recurrent Instability
Evaluation of the patient who presents with poor results after ankle ligament reconstruction requires a thorough history and an indepth knowledge of the primary procedure that was done. Conservative treatment of recurrent instability is identical to that for the preoperative state and should be tried in all patients. Failing conservative treatment, the source of continued instability must be evaluated carefully before proceeding with additional surgery. Clinical and radiographic stress testing should be repeated to evaluate instability. Continued episodes of giving way can be caused by other nonligamentous disorders and should be investigated. Many authors have reported a high incidence of concurrent intraarticular lesions and peroneal tendon disorders with chronic instability, 19,27,33,42,54,67,68,73 and this may continue to give symptoms if not addressed at the initial surgery. Magnetic resonance imaging of the ankle can be helpful in defining concomitant osteochondral fractures, loose bodies, and tendon disorders, but imaging of the reconstructed ligaments is difficult to interpret because of scarring and altered anatomy after surgery.
Surgical planning should include a review of the previous surgeons’ operative report, focusing on the type of procedure that was done and what tissues may have been used during the initial procedure. If the primary procedure was a direct ligament repair, it may be possible to do revision to a standard tenodesis procedure.
Approaching failed previous tenodesis procedures is more complex. Preoperative stress films will help determine which limb of the reconstruction is insufficient. Repositioning of graft material is preferable to complete removal of the previous grafts, and it often is possible to spare one of the limbs of the reconstruction if only one plane of instability is present. For example, if a patient previously has undergone Watson-Jones reconstruction, and preoperative stress films reveal increased talar tilt but stable anterior drawer testing, it is reasonable to harvest the posterior limb of the graft and use this limb to reconstruct the calcaneofibular ligament by attaching it to the calcaneus. Sammarco and Carrasquillo 66 described repositioning of the previous graft material without harvest of a new graft if the original placement was nonanatomic, and the remaining material was acceptable. Snook et al 73 reported that one of the limbs had dissolved completely in a revision tenodesis procedure. In this case, the surgeon must be prepared to harvest a new local or distant graft for reconstruction. In the only series of revision ankle ligament reconstruction surgeries, Sammarco and Carrasquillo 66 reported a 90% success rate using anatomic tenodesis.
In patients who have not responded to reconstruction because of underlying cavovarus deformity, it is important to address the underlying mechanical issues with the hindfoot and forefoot. Simple revision of the ligament reconstruction is doomed to failure because the underlying varus moment will continue to stress and stretch out the ligamentous reconstruction. Because of the marked increase in the magnitude of surgery required for correction of cavovarus deformity, it is wise to discuss the use of more extensive braces before surgical reconstruction. An ankle foot orthosis usually will control the instability, although young active patients will be less likely to accept its limitations. Neurologic workup may be appropriate if the deformity has been worsening, or if motor imbalance is present. In patients with isolated hindfoot varus, a concomitant lateral closing wedge osteotomy can be done simultaneously to correct the heel to approximately 5° valgus. This will protect the reconstruction and normalize the weightbearing axis. If midfoot cavus also is present, the calcaneal osteotomy should incorporate a lateral shift or lateral closing wedge and a proximal shift to decrease the calcaneal pitch angle. If significant forefoot varus is present, the surgeon also may need to do metatarsal osteotomies and plantar soft tissue release to create a plantigrade foot. 69 In the presence of subtalar arthritis and hindfoot varus, subtalar arthrodesis with realignment of the hindfoot in slight valgus should accompany revision of the ankle ligaments.
Postoperative ankle and subtalar stiffness is a commonly reported complication after anatomic and nonanatomic reconstructions. The development of a stiff hindfoot results from one factor or a combination of factors. Graft positioning is extremely important in achieving normal joint motion after surgery. Some nonanatomic ligament reconstructions achieve their results by directly limiting subtalar motion; therefore, postoperative stiffness actually is a desired result. In anatomic reconstructions, malpositioning of the graft limbs may cause an undesired reduction of subtalar or ankle motion.
Gauging the tension of the reconstruction perhaps is the most difficult part of the procedure. To date, no studies have been done to quantify appropriate graft tension with different tenodesis procedures. The hindfoot should be held in eversion while tightening the graft, but it is important to ensure that the graft is not tensioned with the subtalar joint in forced eversion. Overtightening of the graft is a technical error that can lead to symptomatic stiffness and continued pain. 8,12,16
Colville and Grondel 17 observed symptomatic stiffness in two patients who had extended cast immobilization after surgery. Early motion after surgery is important in avoiding debilitating stiffness, and with modern fixation techniques, it is possible to achieve adequate stability so that cast immobilization can be discontinued at 3 to 4 weeks. The patient is allowed to bear weight wearing a boot walker and is started in physical therapy with active and gentle passive motion of the ankle and subtalar joints. Depending on the type of procedure that was done and the degree of stability achieved intraoperatively, more aggressive strengthening and motion are started at 5 to 6 weeks.
Acute and delayed ligament repair have a very low reported incidence of stiffness. 13,30,37,40,64 In a prospective, randomized series comparing modified Brostrom and Chrisman-Snook procedures, Hennrikus et al 31 reported that 9% of patients who had the Brostrom procedure thought the repair was too tight as compared with 28% of the tenodesis procedures being perceived as too tight, but this did not affect subjective results.
The Watson-Jones procedure has been shown to produce significant subtalar stiffness in 14% to 68% of patients, 4,6,12,27,32,33,49 and to cause significant loss of dorsiflexion in 20% to 65% of patients. 3,6,27,33 The Evans procedure is reported to cause significant subtalar stiffness in 28% to 66% of patients 5,7,8,32,36,55,60,63 and is associated with some loss of ankle motion, but less than the Watson-Jones procedure. The Chrisman-Snook procedure has been reported to cause subtalar stiffness in 48% to 70% of patients, 32,73 but several series report few problems with ankle motion after this reconstruction. 72,73 When considering these relatively high percentages of subjective and objective stiffness, it is important to remember that most of these series report a successful outcome in 80% to 90% of patients, therefore loss of motion does not necessarily cause a poor result.
The literature is scant on treatment recommendations for symptomatic stiffness after ankle ligament reconstruction. Colville and Grondel 17 reported that several patients not included in their data were treated for symptomatic subtalar stiffness after Watson-Jones or Chrisman-Snook tenodesis procedures. These patients were treated by taking down the previous ankle ligament reconstruction, then doing an anatomic tenodesis procedure. Subjective outcome improved and subtalar joint motion increased. The approach to revision ankle ligament reconstruction for stiffness should be cautious. If the patient is having debilitating symptoms and the reconstruction clearly is too tight on physical examination, it may be reasonable to do a revision anatomic procedure. If the disability is long standing, or if there is evidence of arthrosis of the subtalar joint, revision is unlikely to significantly improve the patient’s complaints.
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Osaretin B. Idusuyi, MD; and G. James Sammarco, MD, Guest Editors