Acta orthop scand. 51,193-196,1980

CHRONIC LATERAL INSTABILITY OF THE ANKLE A Method of Reconstruction Using the Achilles Tendon

LUDVIG FJELD SOLHEIM, TOR FINN DENSTAD & ASBJ0RN ROAAS

Martina Hansens Hospital, Sandvika, Norway

Reconstruction of the lateral ankle ligaments ad modum Steren, using the medial one third of the Achilles tendon as a nourished transplant is a relatively unknown procedure. Thirty patients operated on using this technique have been evaluated. The mean observation time was 4 years (range 4-16 years). All patients but one had a stable ankle joint and were satisfied. One was reoperated after sustaining a new injury 6 months after the original operation. The method described is a good alternative to other methods of ligamentous reconstruction. The procedure also stabilizes the subtalar joint and corrects recurrent subluxation of the peroneal tendons.

Key words: Achilles tendon; chronic ankle instability; ligaments; ligamentous reconstruction

Accepted 12.v.79

lateral ankle

Persistent instability, pain and muscular weakness following rupture of the lateral ligaments of the ankle is a frequent problem (Freeman 1965, Freeman et al. 1965). Conservative treatment should be tried before surgical procedures. Direct suture of the tom ligaments (Brostrem 1966, Solheim & Aasen 1976) and ligamentous reconstruction using the peroneus brevis (Chrisman & Snook 1969, Ottosson 1978, Watson-Jones 1955) or the peroneus longus tendon (Zenni et al. 1977) are well known procedures.

Steren (1959), using the medial one third of the Achilles tendon as a nourished transplant for reconstruction of the lateral ligaments, stressed the importance of the fact that this method does not interfere with the function of the peroneal tendons thus retaining the natural muscular balance of the foot. Beside our preliminary report (Denstad & Solheim 1977) there has been no other report of this method. This paper presents the result and some modifications of the original operative procedure.

0001-6470/80/010193-04$02.50/0

PATIENTS AND METHODS

Between the years 1962-1978, 30 patients with chronic lateral instability of the ankle joint were operated on using the original or a modified Steren procedure. There were 20 male and 10 female patients with an average age of 35 years (range 19-55 years). The right ankle was involved in 19 and the left in 11 patients. All patients gave a history of primary severe sprain, which in the majority of cases had been in- sufficiently treated, and later chronic unstable ankles for periods ranging from 4-20 years (mean 8 years). On physical examination all patients had instability of the ankle by forced inversion and/or the anterior drawer sign. Anteroposterior and lateral stress X-rays showed marked tilting and anterior subluxation of the talus in most of the patients.

The operative findings showed seven isolated ruptures of the anterior talofibular ligament and two of the calcaneofibular ligament whereas 17 patients had ruptures of both ligaments. In four patients the ligaments were not dissected free. Additional subtalar instability with rupture of the talocalcaneal ligament was found in seven of the patients and two had subluxation of the peroneal tendons.

0 1980 Munksgaard, Copenhagen

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194 L. F. SOLHEIM, T. F. DENSTAD & A. ROAAS

THE THE

TUBER CALCANEI

Figure 1. Dorsal view of the medial one third of the free dissected, rejected and transposed Achilles tendon.

Operative procedure

First session: Through a posteromedial longitudinal incision the medial one third of the Achilles tendon is dissected free, transected proxi- mally at the musculotendinous junction and reflected distally without separating it from the distal insertion on the calcaneus (Figure 1). Steren exposed the region of the lateral malleolus through an anteriorly curved incision in front of the mdeolus, but a c w e d incision behind the malleolus is preferable (Figure 2). The short extensor digitomm muscle is retracted anteriorly to expose the neck of talus, sinus tarsi and the lateral aspect of calcaneus. The free dissected tendon transplant is then pulled through to the lateral side in front of the remaining two thirds of the Achilles tendon and guided subcutaneously deep to the sural nerve but superficially past the peroneal tendons to the lateral mdeolus. The tendon is now threaded through a drill hole in the lateral malleolus, a second drill hole in the neck of the talus and a third drill hole through the lateral aspect of the calcaneus. To prevent limitation of dorsiflexion of the ankle the tendon &odd be fixed to the fibula with the ankle in dorsiflexion

Figure 2. Schematic illustration of the lateral aspect of the ankle shows the surgical incision (E) and the relevant ligaments (A =anterior talojbular ligament, B = calcaneojbular ligament, C =posterior talojbular ligament, D = talocal- caneal ligament). before it is tightened and stitched to the periosteum at the other holes. When the tendon is long enough, it is passed back to the tip of the lateral malleolus and sutured to the periosteum (Figure 3). This modification was performed in 17 patients. Second session: If instability of the ankle persisted after this operation Stmen recommended a second session to take place a minimum of 4 months after the first session (Figure 4).

Postoperative treatment

Mean hospital stay was 14 days. Immobilization in plaster postoperatively was continued for 6 weeks, the last 4 weeks with a walking cast, following by intensive physical therapy.

Follow-up examination

The follow-up period after the operation was 4-16 years, mean 4 years. All patients answered a questionnaire and 16 patients were examined personally.

RESULTS Twenty patients rated their functional results as excellent without complaints and 10 as

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LATERAL INSTABILITY OF THE ANKLE 195

ACHILLES TENDON

Figure 3. The completed modijied procedure of ligamentous reconstruction employing the medial one third of the Achilles tendon.

good with slight complaints such as: sporadic slight distortions (2 patients), occasional moderate swelling (3 patients), slight pain on heavy exertion (4 patients), a little limited dorsiflexion or inversion (6 patients) and minimal symptoms from the Achilles tendon (4 patients). Of the 16 patients examined personally all had a stable ankle. Eleven out of 13 competitive athletes were able to resume their previous sporting activity.

Immediate postoperative complications were one case of superficial infection and two cases of wound necrosis all of which healed rapidly. One patient was reoperated after sustaining a new injury 6, months after the first operation. The second session of the Stprren operation was used and, in addition, an Evans tenodesis, using the peroneus brevis tendon.

DISCUSSION

Stprren (1959) reported seven operations, three of them being two session operations, all giving satisfactory results. In our experience

Figure 4. The second session of St~ren's original procedure: the posterior part of the transposed tendon has been freed from its insertion medially on the tuberosity of the calcaneus and fixed at the insertion of the calcaneofibular ligament on the calcaneus (A).

the first session of the operation is sufficient. The transposition of the Achilles tendon in front of the malleolus represents a reconstruc- tion of the anterior talofibular ligament. Our modified procedure, guiding the tendon back to the fibula, represents a reconstnction of the calcaneofibular ligament, making the second session of the operation unnecessary.

Subtalar instability may occur after sprain causing rupture of the talocalcaneal ligament (Rubin & Witten 1960, Meyer & Lagier 1977) as well as the calcaneofibular ligament (Chrisman & h o o k 1969, Brantigan et al. 1977) and should be diagnosed pre- or peroperatively, since the most commonly used Watson-Jones procedure will not correct this instability (Gillespie & Boucher 1971, Brantigan et al. 1977). Chrisman & SnWk (1969) recommend a modification of the Elmslie procedure using half of the peroneus brevis tendon for treatment of talar and subtalar instability. Brantigan et al. (1977) reported involvement of the subtalar joint in about 10 per cent of patients with lateral in- stability of the ankle compared with the 23 per cent in our material. This might be due

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196 L. F. SOLHEIM, T. F. DENSTAD & A. ROAAS

to the long preoperative period of ankle in- stability and to the exposure of the subtalar joint by this operation. T h e stabilizing effect on the subtalar joint with this operation is satisfactory.

Recurrent anterior displacement of the peroneal tendons due to tearing of the superior peroneal retinaculum may com- plicate sprains of the lateral ligaments (Anderson & LeCocq 1954). Two of our patients developed subluxation of the peroneal tendons after a long period of lateral ankle joint instability. The method described corrects this condition as well as the in- stability of the ankle.

Our results are comparable with those of other methods of ligamentous reconstruction. The method seems especially valuable in the treatment of combined talar and subtalar in- stability or when additional subluxation of the peroneal tendons occurs. The operative procedure is, however, somewhat extensive and the method should perhaps be reserved for cases of more severe instability.

REFERENCES

Anderson, K. J. & LeCocq, J. F. (1954) Operative treatment of injury to the fibular collateral ligament of the ankle. J. Bone J t Surg. 36-A,

Brantigan, J. W., Pedegana, L. R. & Lippert, F. G. (1977) Instability of the subtalar joint. J. Bone Jt Surg. 59-A, 321-324.

Brostr~m, L. (1966) Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures. Acta chir. scand. 132, 551-565.

825-832.

Chrisman, 0. D. & Snook, G. A. (1969) Reconstruction of lateral ligament tears of the ankle. J. Bone Jt Surg. 51-A, 904-912.

Denstad, T. F. & Solheim, L. F. (1977) Reconstruction of the lateral ligaments of the ankle joint ad modum Stmen. In: Proceedings of the Norwegian Orthopaedic Association. Acta orthop. scand. 48, 558.

Freeman, M. A. R. (1965) Instability of the foot after injuries to the lateral ligament of the ankle. J. Bone Jt Surg. 47-B, 669-677.

Freeman, M. A. R., Dean, M. R. E. & Hanham, I. W. F. (1965) The etiology and prevention of functional instability of the foot. J. Bone Jt Surg. 47-B, 678-685.

Gillespie, H. S. & Boucher, P. (1971) Watson- Jones repair of lateral instability of the ankle. J. Bone Jt Surg. 53-A, 920-924.

Meyer, J. M. & Lagier, R. (1977) Post-traumatic sinus tarsi syndrome. Acta orthop. scand. 48,

Ottosson, L. (1978) Lateral instability of the ankle treated by a modified Evans procedure. Actu orthop. scand. 49, 302-305.

Rubin, G. & Witten, M. (1960) The talar-tilt angle and fibular collateral ligaments. J. Bone Jt

Solheim, L. F. & Aasen, A. 0. (1976) Operativ behandling av laterale ankelbllndskader. T. norske Laegejioreen. 96,1192-1 194.

Staren, H. (1959) A new method for operative treatment of insufficiency of the lateral ligaments of the ankle joint. Acta chir. s c a d

Watson-Jones, R. (1955) Fractures and joint injuries. Vol. 2, 4th ed. pp. 817-823. E. b S. Livingstone Ltd., Edinburgh and London.

Zenni, E. J., Grefer, M., Krieg, J. K., Lambed, M. B. & Florez, R. (1977) Lateral ligamentous in- stability of the ankle: a method of surgical reconstruction by a modified Watson-Jones technique. Amer. J. Sports Med. 5 , 78-83.

121-128.

Surg. 42-A, 31 1-326.

117, 501-509.

Correspondence to: Ludvig Fjeld Solheim, Martha Hansens Hospital, 1300 Sandvika, Norway

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