Distal fibulectomy is an uncommon procedure, usually done to address fracture nonunion, tumor resection, or lateral impingement of the fibula on the calcaneus. Although there have been reports in which the ankle was stable after distal fibula resection without a lateral ligament reconstruction, 10,12 cadaveric studies have shown the importance of the distal fibula as a stabilizing structure. 7,19 Because of removal of the bone from which the lateral ligament complex originates, lateral instability may result, potentially leading to tibiotalar arthritis. Jones et al 7 reported significant instability to anterior drawer and talar tilt tests after distal fibulectomy in cadaveric specimens. Instability, as measured by stress radiographs, increased with the amount of bone resected, particularly when above the tibiotalar level. Furthermore, 10- to 15-year followup of patients who have had distal fibulectomy without ligament reconstruction for tumor resection, has shown significant valgus angulation. 12 Although it is debatable whether a lateral ligament reconstruction is necessary after distal fibulectomy, we elected to do a lateral reconstructive procedure because of the potential for lateral instability.
Various surgical techniques have been devised to reconstruct the lateral ligament complex, most of which involve harvesting the patient’s peroneus brevis tendon and rerouting it between the talus, fibula, and calcaneus to reproduce the function of the anterior talofibular and calcaneofibular ligaments. Such methods include the Evans, 5 Watson-Jones, 18 and Chrisman-Snook procedures, 1 along with various modifications. 9,13,15 In general, these reconstructive procedures have had high success rates in restoring ankle stability, with 80% to 90% good to excellent results. 2,8,16 The success of these reconstructions using autograft tissue have obviated the need to use allograft tissue grafts for the most part. There are two reports on the use of lateral ligament reconstruction using fascia lata allografts. 6,11 The intermediate results with a mean of 4.2 years followup has shown 95% good to excellent results. 11 A recent study described the use of autogenous bone-patellar tendon graft to treat chronic lateral ankle instability. 17 The short-term results of this reconstruction at 2.2 years has shown all patients to have improvement in talar tilt. The success of multiple techniques to reconstruct the lateral ligaments may be attributable partly to the inherent stability provided by the lateral malleolus.
We describe a case in which a patient required a distal fibulectomy to relieve painful bony impingement at the tibiofibular joint caused by benign tumors. The patient’s lateral ligament complex originally was reconstructed using autogenous peroneus brevis tendon, but this repair was disrupted after a severe inversion injury. Faced with lateral ankle instability and deficient local tissue, we elected to use a bone-tendon allograft for reconstruction. The allograft tendon was directed from the tibia to the talus in such a way to counteract inversion forces at the ankle. Subtalar motion was preserved by fixing the allograft directly to the talus rather than the calcaneus, avoiding disruption of the subtalar joint mechanics caused by other reconstructive procedures. 3
By using a bony plug for tibial fixation of the allograft, rapid healing was promoted at the proximal tunnel site. Furthermore, the use of an intraosseous tibial tunnel helped maximize the incorporation of tendon graft to host bone. An animal model of tendon healing within a bone tunnel has shown progressive reestablishment of collagen-fiber continuity between the bone and the tendon and increased strength of this interface during a 12-week period. 14 The overall length of the bone-tendon-bone allograft was too long to allow bone plug fixation to the talus; thus, the distal portion of the graft was secured to the talus with a trough and a staple. Therefore, an allograft with only a single bone block, such as Achilles tendon allograft, also would have sufficed.
To our knowledge, this is the first description of a salvage reconstruction for patients who have lateral ankle instability with an absent fibula and deficient peroneus brevis tendon. A followup 14 years after the procedure revealed a stable, painless ankle despite the lack of inherent bony stability.
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