Foot and Ankle Surgery 1999 5: 267–270

Revision lateral ankle ligament reconstructionusing Achilles tendon graft: a case report

B.S. THORNES AND M.M. STEPHENS∗Merlin Park Regional Hospital, Galway and ∗Cappagh Orthopaedic Hospital, Finglas,Dublin, Ireland

SummaryThis report is of a patient with chronic ankle instability, who

underwent revision lateral ligament reconstruction using a graft

from the lateral quarter of the Achilles tendon. The split peroneus

brevis tendon had failed following a previous Evan’s procedure. It

illustrates the use of the lateral quarter of the Achilles tendon as a

graft for reconstruction and illustrates its benefit for revision lateral

ankle ligament reconstruction surgery.

Keywords: ankle instability; revision; stabilization; Achilles tendon;

surgery

Introduction

Operative management of a chronically unstable

ankle is indicated following failure of conservative

functional treatment. Many procedures have been

described to primarily repair or reconstruct the torn

ligament complex. There is little literature regarding

revision surgery following failed primary

reconstruction or re-injury. As many primary

procedures harvest the peroneus brevis tendon as a

graft, a viable substitute must be sought in revision.

We present the case of a patient who required revision

surgery to stabilize his ankle, whose tendon of

peroneus brevis previously had been used. The

patient achieved an excellent result following revision

reconstruction with a graft from the lateral quarter

of the Achilles tendon.

Case historyFigure 1Preoperative stress anteroposterior ankle radiograph showing talarThe patient, a 46-year-old printer and recreationaltilt of 15°.

golfer, presented to the foot and ankle clinic with a

long history of right ankle instability. He had aCorrespondence: Mr M.M. Stephens MSc (Bio Eng) FRCSI,

severe inversion injury to his ankle at age 18, playingConsultant Orthopaedic Surgeon, Cappagh Orthopaedic Hospital,

Finglas, Dublin 11, Ireland (e-mail: footstep@tinet.ie). football, and 2 years later had a lateral ligament

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268 B.S. THORNES AND M.M. STEPHENS

reconstruction performed with the Evan’s procedure,

using the split peroneus brevis tendon. He does

not recall a second significant injury to his ankle

following this surgery, but he presented on this

occasion with progressive pain in his ankle and

recurrent giving way.

Clinically, there was a painless laxity on inversion

stress and on anterior drawer testing, confirmed by

stress radiographs (Fig. 1). These revealed a talar tilt

of 15°. There were also Scranton [1] grade II anterior

tibial osteophytes.

Operative procedureFigure 2Reconstruction using the Achilles tendon.

Through an extended lateral approach, with the sural

nerve being identified and preserved, the ankle joint

was inspected and the anterior tibial osteophytes

excised. A grade III osteochondral flap Postoperative course(3 mm×3 mm) was found on the lateral margin of

The postoperative course was uneventful. The patientthe talar dome and this was debrided and drilled.was discharged home on the fifth postoperative day,Remnants of the old reconstruction were evident,non-weight bearing for 3 weeks, then partial weightincluding a torn split peroneus brevis graft and distalbearing in case for a further 3 weeks. The scotch casefibular tunnel. There was no useful peroneus breviswas removed at 6 weeks and full weight bearing intendon that could be used for reconstruction.an ankle-foot orthosis (AFO) commenced. At 10The lateral 25% of the Achilles tendon wasweeks the AFO was removed and the ankle washarvested, split from its musculo-tendinous junctionpain-free and clinically stable.at the mid-calf level, retaining its distal insertion to

calcaneus intact. This gave a graft length of≈15 cm.

Starting on the posterosuperior extra-articularDiscussion

portion of the calcaneus and exiting at the peroneal

tubercle, a horizontal tunnel through the calcaneus The lateral ligament complex includes the anteriorwas drilled and smoothed with a burr and the graft talo-fibular ligament, the calcaneo-fibular ligamentthreaded through it. A new tunnel was made through and the stronger posterior talo-fibular ligament.the distal fibula to allow a more accurate anatomic Acute injury to the anterior talo-fibular ligament is by

reconstruction. The graft was threaded through from far the most common, and accounts for a significant

posterior tip of the lateral malleolus to its anterior number of casualty attendances in Ireland [2, 3]. It

aspect. The graft was then brought through a tunnel is estimated that between 10% to 30% of acute injuries

from the anterolateral talus to the sinus tarsi, insertion will develop chronic symptoms of instability [4].

point of anterior talo-fibular ligament and then re- Stress radiographs confirm the diagnosis of ankle

sutured onto itself. In this way the calcaneo-fibular, instability. A talar tilt of ≥10°, as compared to the

anterior talo-fibular and lateral talo-calcaneal other side, or an anterior drawer of ≤6 mm, or

ligaments were reconstructed in an anatomical 3 mm greater than the other side, are diagnostic [5].

position (Fig. 2). Magnetic resonance imaging (MRI) is increasingly

The wound was closed over a closed suction drain. being used in the diagnosis of ankle ligament injuries

A below-knee scotch cast was applied with the ankle [6]. They have the advantage of being useful to grade

an acute injury and to diagnose other causes ofin slight eversion and dorsiflexion.

1999 Blackwell Science Ltd, Foot and Ankle Surgery, 5, 267–270

REVISION LATERAL ANKLE LIGAMENT RECONSTRUCTION 269

chronic lateral ankle instability, such as soft tissue as a primary procedure in nine patients, citing the

advantage of not sacrificing the dynamic effect ofimpingement, tendon pathology or osteochondral

lesions. MRI is most useful in the evaluation of high peroneus brevis in preventing inversion of the foot,

but this tendon is relatively small. Rudert et al. [16]demand patients such as professional athletes.

Many procedures for lateral ligament used regional perisosteal flaps to anatomically

reconstruct the anterior talo-fibular and calcaneo-reconstruction have been described, as a result there

is no agreed gold standard procedure. Surgical fibular ligaments. This spares the peroneus brevis

tendon and gave a good to excellent result in 81% ofprocedures can be subdivided in two main ways:

anatomic versus non-anatomic reconstructions, using 90 patients. Primary anatomical reconstruction using

periosteal flaps yielded a better functional outcomeautogenous or synthetic grafts.

Anatomic repair of torn ligaments has been compared to a non-anatomical peroneus brevis

ligamentoplasty in a recent study [19].described by Brostrom [7] which gives good results in

the short-term and has the advantage of not altering There is little literature regarding revision ligament

reconstructive surgery. Sammarco [20] reported onankle biomechanics and through the extensor

retinaculum the subtalar joint can be stabilized [8]. a series of 10 revision procedures, including three

revision Brostrom-type repairs, seven of which usedIn the acute injury conservative functional treatment

is found to be as effective as early operative repair peroneus brevis or plantaris tendon as a graft. All

had good results. Patients with acute injuries should[9]. However, if symptoms of chronic instability

occur, after rehabilitation and a proprioceptive initially be treated conservatively with functional

rehabilitation. If chronic instability develops, primaryprogramme, primary anatomic repair of the torn

ligaments using the Brostrom procedure is probably suturing using the Brostrom procedure should first be

considered. If this fails or is not possible, ligamentousthe treatment of choice [10].

Non-anatomic reconstructions usually use either reconstruction should be performed such as the

Chrisman–Snook technique. If a second injury occursa complete or split portion of the peroneus brevis

tendon. These include the Evan’s procedure [11], and leads to instability, we suggest harvesting the

lateral portion of Achilles tendon as a graft forthe Watson–Jones procedure [12] and the

Chrisman–Snook procedure [13]. Other techniques revision reconstruction when peroneus brevis has

been previously used, because the results arehave been described using grafts from Achilles

tendon [14], plantaris [15], or from a regional flap of excellent, particularly compared to synthetic

materials.periosteum [16].

Reconstructions using peroneus brevis tendon

should be considered after a failed Brostrom repair, Referencesin a hypermobile foot, or if the time from injury to

1 Scranton PE, McDermott JE. Anterior tibiotalar spurs: arepair is greater than 10 years. There is little to choose

comparison of open versus arthroscopic debridement. Foot Anklebetween the different procedures, all offering good 1992; 13: 125–129.

2 Flood HD, Mira AG. A review of sports injuries seen in theresults [17]. The Chrisman–Snook procedure did givecasualty department. Ir J Med Sci 1985; 154: 270–273.a slightly more stable ankle on biomechanical testing

3 Burke P, Buckley N, McShane D et al. Sports injuries and thebut may result in decreased inversion and sub-talar casualty department. Ir Med J 1983; 76: 127–129.

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