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 DOI: 10.1177/1071100713494377

2013 34: 1501 originally published online 14 June 2013Foot Ankle IntAdam G. Miller, Steven M. Raikin and Jamal Ahmad

Near-Anatomic Allograft Tenodesis of Chronic Lateral Ankle Instability  

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Article

Lateral ankle sprain is a common injury that usually resolves with nonoperative treatment.10 Chronic ankle instability occurs when treatment fails and mechanical instability, per-ceived instability and/or recurrent sprains persist. Mechanical dysfunction consists of derangement of the anterior talofibular ligament (ATFL) and/or calcaneofibular ligament (CFL). Left untreated this can lead to continued functional instability, pain, and eventual ankle arthritis.12 Lateral ankle ligament operative repairs in the form of a Brostrom3 imbrication along with a Gould11 or Karlsson16 modification has become the standard of care for chronic ankle instability. These are anatomic repairs which utilize existing soft tissue creating stability. These repairs rely on adequate quality and quantity of the remaining ligamentous and retinacular tissue following an often repetitive injury to

the area. If a paucity of repairable ligament and retinaculum remains, or if the patient has failed a previous operative repair, the repair is at risk for failure. In these clinical sce-narios, operative reconstruction is an option.

Current reconstructive options for these chronic lateral ankle instability patients include “nonanatomic reconstruc-tions” where part of the peroneus brevis tendon is sacrificed and utilized to stabilize the ankle.5,9,24 However, these

494377 FAIXXX10.1177/1071100713494377Foot & Ankle InternationalMiller et alresearch-article2013

1Thomas Jefferson University Hospital, Philadelphia, PA, USA2Rothman Institute, Philadelphia, PA, USA

Corresponding Author:Steven M. Raikin, MD, Rothman Institute, 925 Chestnut St, Philadelphia, PA 19107, USA. Email: steven.raikin@rothmaninstitute.com

Near-Anatomic Allograft Tenodesis of Chronic Lateral Ankle Instability

Adam G. Miller, MD1, Steven M. Raikin, MD2, and Jamal Ahmad, MD2

AbstractBackground: Current operative treatment options for chronic lateral ankle instability include anatomic repairs utilizing existing local tissue and nonanatomic reconstructions sacrificing the peroneus brevis tendon to mechanically stabilize the ankle. Recent studies have modified these techniques to create an anatomic reconstruction utilizing allograft tendons. The purpose of this study was to retrospectively examine the clinical outcomes of a near-anatomic ligament reconstruction utilizing an allograft tendon for recurrent or complex lateral ankle instability.Methods: Twenty-eight patients underwent a near-anatomic allograft lateral ankle ligament reconstruction with a semitendinosis allograft for severe or recurrent lateral ankle ligamentous instability, and all of them were available for follow-up at an average 32 months. Twelve patients had previously undergone lateral ankle ligament stabilizing surgery, 4 had Ehlers Danlos syndrome with poor local tissue, 5 had greater than 30 degrees of varus angulation of talar tilt, while 12 had associated hindfoot varus requiring concomitant reconstruction. Patients were assessed pre- and postoperatively for Visual Analog Scores (VAS) for pain, Foot and Ankle Ability Measures (FAAM), patient satisfaction, radiographic correction, and complications.Results: Median VAS of pain decreased from 8 before surgery to 1 after surgery (P < .001). Median FAAM score increased from 41.7 to 95.2 after surgery (P < .001). Radiographic comparison demonstrated correction of preoperative varus malalignment in all but 1 patient. No patients developed subsequent subtalar arthritis or pain. Three patients had mild persistent instability, all of which was managed nonoperatively. One of the patients with persistent instability also developed chronic regional pain syndrome following surgery. At final follow-up, 25 of 28 patients rated their satisfaction as good or excellent and 3 as fair. No patients required revision surgery.Conclusion: Lateral ligament reconstruction utilizing a near-anatomically placed and tensioned allograft tendon was a viable option in treating recurrent and complex lateral instability. Not sacrificing the peroneal tendons avoided loss of eversion strength. Near-anatomic placement of the allograft provided good ankle stability without sacrificing subtalar motion or predisposition to subtalar arthritis in short-term follow-up.Level of Evidence: Level IV, retrospective case series.

Keywords: ankle instability, outcome studies, ligament reconstruction, allograft tendon

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procedures do not reestablish anatomic ankle kinematics and may lead to ankle and subtalar stiffness.23 In addi-tion, splitting the peroneus brevis tendon to use for the reconstruction may weaken or affect the performance of the main tendon responsible for dynamic stabilization of the lateral ankle complex. Recent studies have modified these techniques to create an anatomic reconstruction utilizing allograft tendon. Anatomic reconstruction using autograft or allograft tendon has become a more attractive option.2,4,7,8,13-15,20-22,25,26 These methods attempt to re-create the ATFL and CFLs to achieve normal kinematics and less postoperative stiffness.

We hypothesized that in patients presenting with severe chronic ankle instability of a complex nature, anatomic reconstruction of the lateral ankle ligament complex utiliz-ing fresh frozen allograft tendon would be a viable option. The purpose of this study was to retrospectively examine the short-term results of a near-anatomic ligament recon-struction utilizing an allograft tendon for recurrent or com-plex lateral ankle instability.

Methods

After obtaining appropriate institutional review board approval, a retrospective database review was undertaken for a diagnosis of lateral ankle instability with a correspond-ing procedure consistent with a tendon allograft reconstruc-tion, utilizing electronic medical record software (SRS Freedom, Version 7.3.145.0, SRS software, Montvale, NJ). Inclusion criteria consisted of all patients having undergone near-anatomic lateral ankle ligament reconstruction utiliz-ing a tendon allograft. In all cases a fresh frozen semitendi-nosis allograft was utilized for the procedure. All cases were managed consecutively by 2 surgeons. Between 2005 and 2011, 28 patients (28 ankles) underwent allograft near-anatomic lateral ankle ligament reconstruction. All were available for complete follow-up at an average 32 months (range, 12-79 months). All documented clinical notes were reviewed for all cases, and included initial preclinical ques-tionnaires completed by the patients, initial history and physical examinations obtained by the senior author, opera-tive reports, and all office notes for a minimum of 1 year postoperatively.

The patients ranged in age from 16 to 69, with a mean age of 47.7 years and median of 49.5 years. The cohort comprised 15 (53.6%) females and 13 (46.4%) males (Table 1). All patients had a clinically unstable ankle on anterior drawer and varus stress testing and had failed prior bracing and physical therapy. Based on the overt clinical findings, stress radiographs were not routinely performed. All patients did undergo pre- and postoperative weight bearing radiographs (anterior-posterior, mortise, and lateral views) to assess alignment, evaluate any degree of arthritic involvement, and assess any degree of talar tilt

during standard (non–mechanically stressed) weight bear-ing. Recurrent pathology or complex pathology were con-sidered indications for the index procedure of lateral ligament reconstruction using the semitendinosis allograft (Table 2). Specifically this included at least 1 of recurrent deformity from failed modified Brostrom-type anatomic reconstruction (9 patients), recurrent deformity from non-anatomic split peroneus brevis reconstruction (3 patients), poor tissue quality due to Ehlers Danlos (4 patients), varus ankle deformity greater than 30 degrees based on weight bearing radiographs with loss of locally usable tissue (5 patients). In addition, 11 patients had associated severe hindfoot varus deformity uncorrectable by orthotics alone requiring concomitant reconstruction who were felt to have too great a deformity to correct and maintain lateral stability with local tissue repair (Brostrom type) alone. Eight patients were also known to have high grade tears of their peroneus brevis tendons requiring reconstruction due to concern that this dynamic stabilizer of the ankle would be suboptimal and augmentation utilizing an allograft would be beneficial.

All but 3 patients underwent concomitant procedures. Concomitant procedures include correction of the cav-ovarus deformity (3), peroneus longus to brevis tendon transfer (4), direct repairs of tears in the peroneus brevis tendon (5), lateral closing wedge Dwyer calcaneal osteoto-mies for hindfoot varus (5), subtalar fusions with lateral closing wedges to correct hindfoot varus with arthritis (3), gastrocnemius recessions (3), and total ankle arthroplasties (7) to address end-stage arthritis at the ankle joint level sec-ondary to the instability. In addition, when local tissue was available (even when suboptimal in quality), simultaneous direct lateral ankle ligament repair (modified Brostrom pro-cedure with Gould modification) was performed. This was done in 10 of the 28 cases.

Operative Procedure

The patient was positioned in a lateral or sloppy lateral position with a wedge or bean bag under the ipsilateral hip. Concomitant procedures were carried out as needed. The exposure for the reconstruction was dependent on associ-ated procedures. If peroneal or lateral ankle joint exposure was required, the procedure was performed through a

Table 1. Patients Included With Follow-Up.

Total patients 28Female/male 15/13Previous surgery 10Left/right ankle 11/17Complications 6

Note. Values represent the patients in each category who underwent lateral ankle ligament reconstruction.

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Table 2. Indications and Procedures Related to Indications for Each Patient.

PatientLigament Reconstruction

IndicationConcomitant Procedure

Indication(s)Dwyer

Osteotomy Brostrom

Peroneal Repair,

TenodesisSubtalar Fusion

Total Ankle Arthroplasty

Gatrocnemius Recession

Cavovarus Reconstruction

1 Instability, failed Brostrom Failed Brostrom × 2 Instability in hindfoot varus Hindfoot varus × × × 3 Instability in hindfoot varus,

failed BrostromHindfoot varus, failed

Brostrom×

4 Instability, Failed Brostrom Failed Brostrom × 5 Instability, failed Brostrom Failed Brostrom × 6 Instability, failed tendon

reconFailed tendon recon × ×

7 Instability, severe ankle varus Severe ankle arthritis × 8 Instability, failed tendon

recon

9 Hindfoot varus, instability in Ehlers Danlos

Subtalar arthritis × ×

10 Instability in Ehlers Danlos, failed Brostrom

Failed Brostrom, peroneal tear

× ×

11 Instability in hindfoot varus Hindfoot varus, subtalar arthritis

×

12 Instability, severe ankle varus Severe ankle arthritis, equinus

× ×

13 Instability, severe ankle varus Severe ankle arthritis × 14 Instability in hindfoot varus Hindfoot varus, severe

ankle arthritis, equinus

× × ×

15 Instability in hindfoot varus Hindfoot varus × ×16 Instability, failed tendon

recon

17 Instability in hindfoot varus Hindfoot varus, severe ankle arthritis

× ×

18 Instability, failed Brostrom Failed Brostrom, peroneal tear

×

19 Instability, failed Brostrom Failed Brostrom, peroneal tear

×

20 Instability in Ehlers Danlos Failed Brostrom, peroneal tear

× ×

21 Instability with poor local tissue

Augment reconstruction ×

22 Instability in Ehlers Danlos, failed Brostrom

23 Instability in hindfoot varus, severe ankle varus

Severe ankle and subtalar arthritis

× ×

24 Instability in hindfoot varus Hindfoot varus ×25 Instability, severe ankle varus Peroneal tear × 26 Instability, failed Brostrom Failed Brostrom × 27 Instability in hindfoot varus Hindfoot varus,

peroneal tear× ×

28 Instability in hindfoot varus Hindfoot varus, peroneal tear

× × ×

Total 5 10 9 3 7 3 3

Note. The first column indicates the surgical indication for the ligament reconstruction. The second column gives the reason for the additional procedures listed in the columns to the right.

curvilinear incision along the path of the peroneal tendons, posterior to the fibula. The flap was elevated to gain access to the ATFL and CFL. The decision to use the allograft reconstruction was made when the ATFL and CFL were deemed to be markedly deficient at the time of surgery. If the procedure was planned, as with cases of Ehlers Danlos syndrome where the local tissue quality was known to be deficient, a more percutaneous approach was used. Four small incisions were utilized, 1 over the ATFL insertion

footprint into the talus, a second at the ATFL insertion into the anterior distal fibula, 1 posterior to the distal fibula, and a final incision over the lateral calcaneus at the CFL insertion. Whether done open or percutaneously, 3 bone tunnels were created through which the allograft tendon was passed (Figure 1). Initially a Beath pin was drilled from lateral to medial across the talar neck at the footprint of the ATFL insertion point. This could be located by direct visualization or under image intensification

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guidance. The semitendinosis allograft was thawed and soaked in antibiotic solution prior to use. A whip stitch was run through each end of the tendon, tubularizing the tendon and leaving the stitch to be utilized to pull and tension the tendon through the bone tunnels. Adequate length of allograft tendon was confirmed, usually 20+ cm. We usu-ally pretensioned the tendon prior to implantation, but the necessity for this remains controversial.18 The thickness of each end of the tendon was measured utilizing a known diameter measuring system. The true ATFL and CFL liga-ments are flat broad structures, which cannot be truly reproduced utilizing an allograft tendon. The round and bulky structure of the tendon was felt to be needed to ensure adequate strength of the reconstruction. The tendon must be able to freely slide through the chosen diameter tunnel. In most cases there was a thinner and thicker end to the tendon. The thinner end would usually slide through a 5 mm tunnel or was trimmed to allow easy passage through this diameter tunnel. A 5 mm tunnel was then drilled across the talus over the Beath pin at the isometric point of the insertion of the ATFL just anterior to edge of the cartilage of the talar dome, close to the true footprint of the ATFL attachment. A second bone tunnel was the made in the dis-tal fibula, again drilled over a Beath pin. The tunnel started anteriorly at the origin of the ATFL on the anterior distal fibula and exited the fibula posteriorly between the inser-tion points of the CFL and posterior talofibular ligament which was a relative bare spot of the distal fibula and was

confirmed with pin placement prior to drilling. Care was taken not to fracture the cortex of the fibula while making the bone tunnel. The allograft was passed at this point from the posterior fibula through the fibular bone tunnel and then from lateral to medial through the talar bone tun-nel. The graft was fixated into the talar bone tunnel at this point utilizing an appropriately sized (usually 5.5 mm) interference screw. A final tunnel was then created at the insertion point of the CFL on the calcaneus which exited the medial aspect of the calcaneus through a small counter incision. The path of the reconstructed ATFL was oriented approximately 130 degrees with respect to the CFL, cor-responding to the normal anatomy. While this does not truly replicate the CFL insertion into the fibula, it allowed a single straight bone tunnel to be created in the fibula, minimizing the risk of fracture potentially occurring with a double drill hole. In addition, this method allowed any remnant of the CFL to be used to augment the reconstruc-tion. The allograft was passed under the peroneal tendons, replicating the CFL, and along the lateral aspect of the calcaneus beneath the skin utilizing a curved hemostat. The Beath pin was used to pull the tendon from lateral to medial through the calcaneal bone tunnel, exiting through the medial counter incision. The ankle was placed in slight eversion, with the talus in neutral relative to anterior dis-placement and the graft maximally tensioned and fixed into the calcaneus with a second biotenodesis screw. Following wound closure, the limb was immobilized in slight eversion and neutral flexion for a total of 6 weeks, with the patient non–weight bearing.

Outcomes

Patients were assessed for preoperative and postoperative outcomes based on radiographic appearance (specifically measurement of talar tilt on weight-bearing mortise views), Foot and Ankle Ability Measure (FAAM) score,19 Visual Analog Scale (VAS) for Pain, and patient satisfaction rat-ings. The primary outcome variable was the ADL subset of FAAM scoring. Preoperative scores were collected pro-spectively. All complications were noted. Postoperative scores were calculated from the last follow-up data. All data collection and patient evaluations were undertaken by an assistant independent from the surgeon.

Statistical Methods

Mann–Whitney medians testing was reported for VAS pain scores and FAAM outcome scores. Patient satisfaction scores were graded as follows: excellent with minimal or no complaints and stable ankle; good with some complaints of residual pain or numbness with stable ankle; fair with ankle instability and minor complaints; poor with ankle instability and significant complaints.

Figure 1. Lateral radiograph of ankle with fibula tracing. Placement of allograft is demonstrated, originating at anterior talofibular ligament footprint on talus, passing through fibula, and inserting on calcanealfibular ligament footprint on calcaneus.

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Source of Funding

There was no source of funding for this project.

Results

Median VAS of pain decreased from 8 before surgery to 1 after surgery at time of final follow-up (P < .001). Median FAAM score increased from 41.7 to 95.2 after surgery (P < .001; Table 3).

All incisions healed without complication or infection. Two patients experienced residual numbness in the super-ficial peroneal nerve distribution but this did not cause any functional impairment. Five patients had a preoperative varus talar tilt of greater than thirty degrees on standing weight bearing radiographs. The average tilt in these 5 patients was 37 degrees (range, 30-45 degrees). In addi-tion, 7 other cases had milder talar tilting of 5-20 degrees. Radiographic comparison demonstrated less than 5 degrees of postoperative varus tilt at the ankle joint in 27 cases (Figures 2a and 2b), however 1 patient was found to have undercorrected hindfoot varus and had a 5 degree persistent tilt of the talus within the ankle mortise. To date, no patients developed signs of subsequent subtalar arthri-tis radiographically or pain clinically. Clinical subtalar motion was comparable to the contralateral side, exclud-ing 3 patients who underwent subtalar fusions. Peroneal tendon strength was 5/5 in 20 patients and 4/5 in 8 patients. These results corresponded to 2 patients who had mild persistent instability, 1 of whom experienced continued varus alignment treated with orthotic inserts and the other had a traumatic instability in addition to developing chronic regional pain syndrome (CRPS) following sur-gery. A third patient who had undergone a revision follow-ing a failed Brostrom, repair of a peroneal tendon tear and revision arthroscopic microfracture of an osteochondral lesion of the talus at the time of her surgery, fell down the stairs 5 months postsurgery injuring her ankle. She com-plained of persistent functional instability of her ankle but with a negative anterior drawer test. MRI evaluation 18 months following surgery demonstrated an intact anterior talofibular allograft ligament with a persistent osteochon-dral lesion in her talus. None of these patients required

revision surgery or long-term bracing, with all 3 rating their results as fair. Based on patient satisfaction surveys, 25 of 28 (89%) patients rated their satisfaction as good (8, 28.6%) or excellent (17, 60.4%; Table 4). Three patients had continued instability graded as fair. None of the patients, including the patient with CRPS, rated their result as poor and all said they would undergo the proce-dure again.

Discussion

The purpose of this study was to examine the results of lat-eral ankle ligament reconstruction using semitendinosis allograft in a near-anatomic fashion. Our hypothesis was that in patients presenting with complex or recurrent chronic mechanical lateral ankle instability undergoing near-anatomic reconstruction with allograft tendon would yield satisfactory results, without weakening the peroneal tendons or developing stiffness of the subtalar joint. Based on our results, we found this to be correct.

Near-anatomic lateral ankle ligament reconstruction technique is useful in a complex group of patients. In the current study this included patients with failures of prior ligament reconstructions, presence of concomitant pathol-ogy and malalignment, or intrinsic ligamentous laxity. Primary repairs have been reported to fail in 10% of patients overall.17 These more complex patients require a robust reconstruction instead of ligament repair. Allograft tendon is particularly useful over autograft options due to the potential morbidity of harvesting the peroneus brevis tendon, in addition to allowing near-anatomic placement of the graft near the footprint of the ATFL and CFL within the talus, fibular and calcaneus, respectively. This acts to re-create natural kinematics of the hindfoot while limiting stiffness of the subtalar joint associated with nonanatomic reconstructions.1 The ease and safety with which allograft tendons are obtained affords minimal risk to the patient.6 While we can conclude clinically that the near-anatomic reconstruction was successful, this study was unable to make any conclusion in comparing tendon reconstruction methods directly. A prospective comparison study is needed for further information discerning the differences between anatomic and nonanatomic reconstructions.

Limitations to this study include the retrospective nature and lack of control group for comparison. A control group of this nature becomes difficult to obtain since these patients have often exhausted other means of treatment. Again, further research in the form of prospective com-parative studies is still needed. Bias could be considered in this study, but this was minimized by utilizing the pro-spectively collected patient data and the senior author being blinded to data collection and analysis. All question-naires and scoring tools were delivered by staff other than the operating surgeons.

Table 3. Outcome Scores in Final Follow-Up, Calculated From Mann–Whitney Medians.

Visual Analog Scale Pain Score

(median)

Foot and Ankle Ability Measure

(median)

Presurgical 8 41.67Postsurgical 1 95.2495% CI for difference 5.00–7.50 39.29–53.78P value <.001 <.001

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Conclusion

Lateral ligament reconstruction utilizing a near-anatomic, tensioned allograft tendon was a viable option in treating recurrent and complex lateral instability. Maintaining peroneal tendons prevented loss of eversion strength, while near-anatomic placement of the allograft provided good ankle stability. Based on our short-term results, this did not appear to sacrifice subtalar motion or predispose the patient to subtalar arthritis. Despite poor local tissue quality, this technique demonstrated good short-term results.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Figure 2. Radiographic comparison demonstrating preoperative varus malalignment (a) and final correction (b). Patient had severe ankle instability with cavovarus and both peroneals were partially torn. The patient underwent combined Brostrom with semitendenosis reconstruction, Dwyer osteotomy, first MT closing wedge osteotomy, and peroneal longus to brevis tendon transfer.

Table 4. Patient Satisfaction Scores.

Satisfaction Score

Excellent 17Good 8Fair 3Poor 0

Note. Excellent grade is a patient without complaints and stable ankle. Good is a patient with minor complaints of pain or other but with stable ankle. Fair is instability of the ankle and minor complaints. Poor is major complaints or complications and instability.

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