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Salvage Reconstruction for Lateral Ankle Instability Using a Tendon Allograft

Su, Edwin P., MD*; Healey, John H., MD**

Clinical Orthopaedics and Related Research®: October 2003 - Volume 415 - Issue - p 232-238
doi: 10.1097/01.blo.0000092976.12414.b0
SECTION II ORIGINAL ARTICLES: Foot/Ankle
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Lateral ligamentous instability may result after an inversion injury to the ankle. Although it generally responds well to nonsurgical treatment, recurrent cases may warrant surgical intervention. There is extensive literature detailing various procedures designed to restore lateral ankle stability. We describe a case in which a patient had a distal fibulectomy for multiple symptomatic osteochondromas, with reconstruction of the lateral ligament complex using peroneus brevis tendon. The patient subsequently disrupted this surgical construct with a severe inversion injury and had recurrent lateral ankle instability. The lateral ligament complex then was reconstructed using a tibiotalar bone-tendon allograft directed to counteract inversion forces. Fourteen years after the procedure, the patient remains satisfied with a painless, stable ankle. The described technique provides a salvage reconstruction of the lateral ligament complex using allograft tissue, in the unique setting of an absent fibula and deficient peroneus brevis tendon.

From *The Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY 10021;

**Memorial Sloan-Kettering Cancer Center, Weill Medical College of Cornell University, 1275 York Avenue, New York, NY 10021.

Reprint requests to Edwin P. Su, MD, The Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY 10021. Phone: 212-774-2954; Fax: 212-774-7606.

Received: August 26, 2002.

Revised: November 22, 2002.

Accepted: January 8, 2003.

Lateral ankle instability may develop in as much as 20% of patients who sustain an inversion-type injury to their ankle. 2 Although most patients are treated successfully by nonoperative management, there may be continued lateral ankle instability that remains symptomatic. Numerous procedures have been devised to reconstruct the talofibular and calcaneofibular ligaments, the primary stabilizers of the lateral ankle. Most of these techniques rely on the use of the peroneus brevis tendon to restore lateral stability.

We describe a case in which a patient had a distal fibulectomy for multiple symptomatic osteochondromas refractory to conservative treatment, with reconstruction of the lateral ligament complex using the peroneus brevis tendon in a modified Elmslie technique. 4 The patient was recovering uneventfully from this index procedure until she severely twisted her ankle, disrupting the ligament reconstruction. The lateral ligament complex then was reconstructed using a tibiotalar bone-tendon allograft. She remains satisfied with this procedure, having a painless, stable ankle 14 years after surgery.

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CASE REPORT

The patient initially presented at the age of 29 years with left ankle pain. She was diagnosed with multiple hereditary osteochondromas, and her maternal grandmother, mother, and sister also were afflicted with the same condition. The patient had numerous operations over the years to remove symptomatic exostoses, most notably three prior procedures in the left ankle region. She had been experiencing left lateral ankle pain with weightbearing for approximately 4 months, particularly with eversion and valgus stress.

The patient had significant tenderness over the distal tibiofibular junction. She had 10° dorsiflexion of the ankle and 40° plantar flexion. There was no instability, with a normal talar tilt and anterior drawer. Radiographs (Fig 1) showed multiple tibial osteochondromas arising from the distal lateral cortex, extending into the tibiofibular joint and causing deformation of the fibula and impingement in the tibiofibular syndesmosis. The patient continued to have intractable pain despite nonoperative measures including injections, immobilization, and activity modification. Bracing served only to exacerbate the patient’s symptoms because of tenderness directly over the distal fibula. Because conservative treatment had failed, it was decided to resect the tibial osteochondromas and distal fibula for pain relief.

Fig 1A

Fig 1A

Figure

Figure

Approximately 9 cm of the distal fibula was excised and the numerous lateral tibial osteochondromas were resected (Fig 2). The peroneus brevis tendon was used for the lateral ligament reconstruction, passing it from the anterolateral talus to the tibia, and then from the tibia to the calcaneus, in a modified Elmslie fashion. 4 Postoperatively, she wore a cast for 6 weeks, followed by weightbearing wearing an aircast. The patient’s recovery was uncomplicated until she had a major inversion injury to the ankle 3 months postoperatively. She had repeated episodes of instability despite bracing, indicating failure of the prior lateral ligament reconstruction.

Fig 2A

Fig 2A

Figure

Figure

There was no other local tissue to use for reconstruction and the plantaris tendon was absent; therefore, a tendon allograft with a bone block was used to reconstruct the lateral ligament complex. A patellar bone-tendon-bone allograft was prepared to a 9 mm width, with tapered bone plugs. A small medial incision was made over the distal tibia to allow for drilling of a tibial tunnel from proximomedial to distolateral (Fig 3). This was done in the midaxial line of the tibia, in the coronal plane. A 9-mm reamer was used to enlarge the tunnel. The allograft then was passed from medial to lateral, wedging the bone plug with an interference fit. The excess bone plug on the medial side was trimmed. The original intent was to use bone blocks for fixation to the tibia and talus; however, the graft was too long to use a bone block on the talar side. Thus, the distal bone plug was excised and a bony trough was made on the lateral aspect of the talus. While the ankle was maintained in a slightly everted position, as recommended by Snook et al, 16 the tendon graft was fixed to the lateral aspect of the talus using a small staple. The allograft was fixed to the talus as described to counteract inversion forces at the ankle while maintaining subtalar motion. The excess patellar tendon was fanned out and approximated to the surrounding anterolateral tissue, thereby reinforcing the reconstruction.

Fig 3A

Fig 3A

Figure

Figure

The ankle was casted and the patient was nonweightbearing for 6 weeks. At that point, she wore a weightbearing cast for 6 weeks, followed by an aircast for an additional 6 weeks. Fourteen years after the reconstruction, the patient has a painless left ankle, is not using any supportive devices, and has had no additional episodes of instability. She has 10° dorsiflexion, 40° plantar flexion, excellent subtalar motion, and negative anterior drawer and talar tilt tests. Radiographs (Fig 4) show the reconstructed ankle, with excellent alignment and incorporation of the bone plug within the tibial tunnel.

Fig 4A

Fig 4A

Figure

Figure

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DISCUSSION

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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References

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