Background Several minimally invasive anatomic reconstruction techniques of the lateral ligaments have been introduced for the treatment of chronic lateral ankle instability. However, these strategies may not always follow accurate ligament anatomic attachments, especially in the construction of the fibular bone tunnels. Objectives This study reported a new percutaneous technique for reconstruction of the ligaments of lateral ankle anatomi- cally with a Tightrope system. Methods From April 2016 to August 2016, 25 ankles of 24 patients with chronic ankle instability underwent our new per- cutaneous anatomic reconstruction of the lateral ligaments with a Tightrope system. The operation was performed through several small incisions. The fibular tunnel was made obliquely from the anteromedial side of lateral malleolus tip towards retro-malleolar cortex. The graft was fixed in the tunnel with the help of a Tightrope system. The calcaneal tunnel and talar tunnel were made as our previous method. The mean final follow-up was 12.2 months (range 10–14). Visual Analogue Scale for pain, American Orthopaedic Foot and Ankle Society score, and patients’ subjective satisfaction were used to measure clinical outcomes. Preoperative and postoperative stress tests were performed and radiographic parameters were measured. Results The Visual Analogue Scale decreased from 3.0 ± 1.4 to 1.3 ± 0.8 at the last follow-up (p < 0.01). The American Orthopaedic Foot and Ankle Society score was improved from 70.2 ± 5.4 preoperatively to 92.4 ± 5.3 at the final follow-up (p < 0.01). Radiologically, the mean anterior talar displacement was 13.1 ± 2.7 mm preoperatively versus 5.6 ± 1.3 mm at last follow-up (p < 0.01),and the mean varus talar tilt angle was 15.0° ± 2.4° preoperatively versus 5.6° ± 1.9° at the last follow-up (p < 0.01). Patients were satisfied (‘excellent’ or ‘good’) in 23 ankles (92%). Two patients reported residual instability but less apprehension than the preoperative condition. Conclusions Percutaneous anatomic reconstruction of the lateral ligaments of the ankle with a Tightrope system is an ana- tomic and effective procedure for the treatment of chronic lateral ankle instability. Keywords Allograft · Anatomy · Ankle · Ligament · Minimal invasive · Tightrope Introduction commonly reported, with good to excellent results. However, these strategies may not always follow accurate ligament Chronic ankle instability (CAI) is one of the most common anatomic attachments, especially in the construction of the problems in foot and ankle surgery. Despite adequate pri- fibular bone tunnels. After some years of experience with mary treatment including immobilization and physical ther- open approaches and percutaneous techniques, we adopted apy, approximately 20–40% of patients present with persis- a new minimally invasive technique for reconstruction of tent instability and require surgical intervention. Among the the ligaments of lateral ankle anatomically with a Tightrope techniques used, anatomic reconstruction is one of the most system. The rationale for this technical stratagem is based on cadaver studies that demonstrated the original footprints of anterior talofibular ligament (ATFL) and calcaneofibular * Xiangyang Xu ligament (CFL) on the lateral malleolus [1, 2]. The subjec- email@example.com tive and objective function as well as radiographic changes Department of Orthopedics, Shanghai Ruijin Hospital North, of the ankle with this minimally invasive procedure was Shanghai Jiao Tong University School of Medicine, No. 999, evaluated in this study. Xiwang Rd, Shanghai 201800, China Vol.:(0123456789) 1 3 1550 Archives of Orthopaedic and Trauma Surgery (2018) 138:1549–1555 Methods We analyzed 25 ankles of 24 patients who underwent per- cutaneous lateral ligaments reconstructions using allograft with a Tightrope system between April 2016 and August 2016 for the treatment of CAI. These patients had ankle instability or repetitive ankle sprain injuries despite a minimum of 6 months of non-operative treatment with a rehabilitation program focused on proprioceptive training and peroneal strengthening. Indications for ligament reconstruction All patients included in this study satisfied at least two of the following criteria: (1) generalized ligamentous laxity, (2) previously failed reconstruction of the lateral ligaments, (3) obesity (body mass index more than 25), (4) high demand heavy athletes or laborers, (5) poor qual- Fig. 1 Schematic drawing of the reconstruction method ity tissue during the intraoperative evaluation, (6) severe ankle instability, significant ankle laxity with a ≥ 10° dif- At the recipient site of the ankle, we made three small ference in talar tilt angle when compared with the opposite incisions of 5 mm each at the anteromedial side of the side or an absolute talar tilt angle ≥ 15°, and more than lateral malleolus tip, talar neck, and the middle portion 10 mm of anterior talar displacement. All patients with of the calcaneus. the following surgery contraindications were excluded: A guide wire was introduced through the center of medial (1) ankle infection, (2) fracture, (3) ankle arthritis > grade and lateral cortex of lateral malleolus in an upwards and 2 according to Morrey and Wiedeman classification, (4) posterior direction from the anteromedial side of lateral functional instability without mechanical instability on malleolus tip, towards to retro-malleolar cortex about 2.5 cm stress radiographs. above the lateral malleolus tip (Fig. 2b). To ensure proper positioning of the cortical button, a fourth incision was made at the penetrating site of the guide wire tip, just behind the Operative technique posterior fibular cortex. A fibular tunnel 4.5 mm in diam- eter was created over the guide wire using a drill bit while After general or continual epidural anesthesia, the patients protecting of the peroneal tendons (Fig. 2c). It is critical to were supine with a pneumatic tourniquet on the proximal ensure that the tunnel was placed in the center of the fibula thigh. A pad was routinely placed under the affected but- in the coronal plane to minimize the risk of tunnel compro- tock to rotate the limb medially. mise or blowout. We performed an arthroscopic examination of the ankle The allograft was trimmed to a minimum of 14 cm (in immediately before reconstruction of the lateral ligaments length) × 8 mm (in width) × 1 mm (in thickness) after cryo- to evaluate and treat any accompanying intraarticular genic processing. Load the graft through the implants by lesions through the standard antero-medial and antero- folding it symmetrically over the Tightrope loops. Stitch lateral arthroscopy portals. The ankle joint was explored approximately 1.5 cm of each graft end with a high-strength thoroughly to identify all lesions (condition of the anterior nonabsorbable no. 2 suture. talofibular ligament, medial collateral ligament, synovium, The cortical button leading line was passed through the cartilage, and bone). fibular tunnel with the help of a guide eyelet wire (Fig. 2d). Figure 1 shows sagittal illustrations of the reconstruc- Then the cortical button was advanced out of the fibular tion method performed in the lateral positon. tunnel. The graft was then pulled back to confirm the button The semitendinosus allograft ligament (Osteorad Ltd, was seated. After that, the cortical button was tightened in Shanxi, China) and Tightrope system (ACL TightRope RT, its position (Fig. 2e). Arthrex, USA) was used for anatomic reconstruction of the For positioning of calcaneal tunnel, an eyelet wire was anterior talofibular ligament and calcaneofibular ligament introduced towards the posterior, inferior, and medial edge using a percutaneous minimally invasive technique (Fig. 2a). of the calcaneus as described by Xu et al. . A 4.5 mm drill 1 3 Archives of Orthopaedic and Trauma Surgery (2018) 138:1549–1555 1551 Fig. 2 Percutaneous anatomic reconstruction of the lateral ligaments e Introduction of allograft and positioning of the cortical button. f of the ankle with a Tightrope system. a Semitendinosus allograft Creating the talar and calcaneal tunnels. g, h Passing and fixation the ligament and Tightrope system. b, c Creating the fibular tunnel. d, graft ends to the talar and calcaneal tunnels. i Sutured incisions was used to create a tunnel that was then widened to 7 mm short-leg cast. Isometric dorsiflexion strengthening of the with an approximate depth of 2.5 cm. The talar tunnel was ankle was allowed to reduce stiffness at 3 days after opera- made by a similar method (Fig. 2f). The ends of the tendon tion. The cast was changed to an ankle orthosis (VACO cast, were then passed above the bone surface to the incisions at Company OPED, Germany) at 2 weeks after surgery. The the talar neck and calcaneus (Fig. 2g, h). patient was advanced to partial weight bearing by 3 weeks. With the ankle and foot in the neutral position, two Full weight-bearing started at 6 weeks postoperatively. The 7 mm × 23 mm biodegradable inference screws (BioCryl , ankle orthosis was removed at 10 weeks after operation, and Depuy Miteck, Raynham, MA) were used to fix each end of the patients transitioned to a normal shoe with a soft brace. the tendon graft in the talar neck and calcaneus in a lateral- Jogging was resumed at 12 weeks after operation. to-medial direction along the guide wire while maintaining tension on the graft (Fig. 2i). The locations of cortical button Clinical evaluation and interference screws were examined under fluoroscopy (Fig. 3). All patients were evaluated from both the clinical and radio- graphic perspective. The clinical outcomes were evaluated Rehabilitation protocol with Visual Analogue Scale (VAS) for pain, American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot Postoperatively, the affected ankle was immobilized in a (AOFAS-AH) score, and patients’ subjective satisfaction. valgus position and a weight free manner using a U-shaped The questionnaires of VAS and AOFAS-AH were completed 1 3 1552 Archives of Orthopaedic and Trauma Surgery (2018) 138:1549–1555 Fig. 3 Postoperative radio- graphic images showing the locations of the cortical button and interference screws before surgery and at last follow-up. Patients’ subjective sat- preoperatively to 92.4 ± 5.3 at the final follow-up (p < 0.01). isfaction level was graded as excellent, good, fair, or poor. Radiologically, the mean anterior talar displacement was Excellent is referred to full activity, including strenuous 13.1 ± 2.7 mm preoperatively versus 5.6 ± 1.3 mm at last sports, with no pain, swelling, or giving way of the ankle. follow-up (p < 0.01), and the mean varus talar tilt angle was Good is referred to occasional aching of the ankle but only 15.0° ± 2.4° preoperatively versus 5.6° ± 1.9° at the last after strenuous exercise, no giving way or feeling of appre- follow-up (p < 0.01). Patients were satisfied (‘excellent’ or hension. Fair is referred to residual instability and remain- ‘good’) in 23 ankles (92%). The patient satisfaction level for ing apprehension but less instability and apprehension as the other two cases was ‘fair’. They reported residual insta- compared with the patient’s ankle condition before surgery. bility but less apprehension than the preoperative condition. Poor is referred to recurrent ankle instability and giving Surgical complications were reported in three patients. way, unchanged or worse in normal activities with episodes No superficial wound infections occurred. One patient had of pain and swelling. Preoperative and postoperative stress injury of the branch of superficial peroneal nerve and a sen- radiographs were taken using a TELOS stress device. Radio- sory disturbance on the lateral aspect of the foot and did graphic parameters included the anterior talar displacement not influence the final clinical result. Another two patients and varus talar tilt angle between bony surfaces of the talus reported soft tissue irritation from the cortical button. No and tibia. granuloma formation or osteolysis in adjacent bone occurred in the patients. The satisfaction in one of them was fair, Statistical methods because of chronic ankle pain and residual instability. There has not been a need for reoperation in any of the patients. Statistical analysis was performed using SPSS software version 18.0 (SPSS Inc., Chicago). Changes in the VAS, AOFAS-AH score, and radiographic parameters before and after operation were analyzed by Wilcoxon test. P values less Discussion than 0.05 were considered statistically significant. In this study, the patients achieved satisfactory clinical results after lateral ankle reconstruction using a percuta- Results neous anatomic reconstruction technique with a Tightrope system. Our reconstruction method restored the normal anat- This study group included 9 males and 15 females. The omy by positioning the allograft at the original point liga- average age at the operation time was 30.8 years (range ment origin and insertion. There are two patients reported 18–50). The mean final follow-up was 13.9 months (range a residual instability on uneven ground, but they thought 12–16). The VAS decreased from 3.0 ± 1.4 before surgery it was better than the preoperative condition. This study to 1.3 ± 0.8 at the last follow-up (p < 0.01). The AOFAS- supports the effectiveness of this approach in this group of AH score was significantly improved from 70.2 ± 5.4 patients with severe instability. 1 3 Archives of Orthopaedic and Trauma Surgery (2018) 138:1549–1555 1553 To date, many surgical techniques have been described to while Xu and Wang et al. [3, 22] made a ‘Γ’ shaped fibular manage CAI. These techniques and their modifications fall tunnel. into three categories: non-anatomic reconstruction, anatomic To perform an anatomic reconstruction, the anatomy must repairment, and anatomic reconstruction. Non-anatomic be well understood. When performing an anatomic recon- reconstruction uses various configurations of local tendon struction of the lateral ligament complex, the surgeon has grafts to accomplish the restriction function of the ligament little guidance on where to place bony tunnels. Based on the without repair of the injured ligaments. Several techniques research of eight unpaired fresh-frozen cadaver feet, Neu- have been described, including partial or complete tenode- schwander et al.  demonstrated that the CFL and ATFL sis from the peroneal tendon or Achilles tendon; or allo- have a single confluent footprint on the anterior border of grafts mimicking the function of the original ligament such the distal fibula. Wenny et al. [1 ] also found that the fibu- as the Chrisman–Snook (CS) , the Evans procedure  lar attachment of the CFL was suited direct adjacent to the and the Watson Jones procedure . Anatomic repairment fibular attachment of the ATFL. Therefore, these so-called is to restore normal anatomy and joint mechanics by in situ anatomic reconstruction procedures could not fix the graft repair of the injured ligament. Anatomic repairment includes tendon at the original attachment point of ATFL and CFL repair ligaments by either shortening and reattaching them anatomically. The reconstructed ligament in non-anatomic to the bony surfaces, or augmenting them with surrounding location will certainly have some effect on ankle rotational structures to enhance the repairment. A good example is the kinematics and kinetics during normal gait [23, 24]. In our classic Brostrom–Gould procedure , which empowers the study, we restored the ATFL and CFL anatomically from one original ligaments with the extensor retinaculum and has common fibular origin, which better mimic the biological proved to be a strong procedure without sacrificing other function of primary ligaments and should have resulted in anatomic structures. Anatomic reconstruction procedures more normal ankle kinematics. Besides, the graft in ana- use tendon grafts to recreate joint biomechanics anatomi- tomic location is much likely to reduce soft tissue impinge- cally by replicating the anatomic positions of the ATFL and ment and friction with lateral malleolus, articular surface of CFL origin and insertion sites. They vary in the means by the talus, or peroneal tendon. which they attain that positioning, including the number and This procedure has several other advantages besides accu- angle of tunnels in the fibula and the fixation techniques rate anatomic localization. Creating a straight fibular tun- selected in each bone tunnel location. nel is easier than previous ‘Γ’ shaped fibular tunnel [3 , 22]. Non-anatomic techniques have been used in the past, but Furthermore, it spends less time with less intraoperative tun- currently are not the procedure of choice, as such proce- nel fracture probability. Two branch with a conjunct fibular dures do not reestablish the ankle kinematics, but stabilize outlet using Tightrope fixation will also reduce the risk of the ankle and results in ankle stiffness [8 , 9]. Now Bros- micromotion of the graft within the unfixed fibular tunnel, trom–Gould procedure is considered to be the gold standard compared to previous bidirectional outlets that might have for surgical treatment of CAI [7, 10–13]. However, anatomic resulted in adjacent synovitis due to impingement or wear- repairment does not fully address special conditions such ing of the graft. The traditional open techniques with larger as severe instability or revision surgery. This procedure incision put this anatomic region at a higher risk for colo- may not provide adequate stability and lead to recurrence nization with microorganisms, nerve injury, ankle stiffness, using the weakened and scarred remnants. Subsequently, and potential problems with wound healing than minimally researchers have described several anatomic reconstruc- invasive surgeries. This percutaneous technique has some tion procedures using autograft or allograft tendon [14, 15]. merits for lateral ankle ligament reconstruction because it Studies have demonstrated that anatomic reconstruction can can access the same anatomic structures as an extensible improve lateral ankle instability and restore normal ankle approach without increasing the morbidity. Limited expo- motion [16–19]. Besides, there has been a recent trend of sure reduces the likelihood of damage to the superficial pero- minimally invasive anatomic reconstruction of the lateral neal nerve. The small incisions also have cosmetic appeal to ankle ligaments for CAI, which has been found both feasi- young patients. It can be safely combined with arthroscopy ble and reproducible. However, there is still large room to as it preserves tissue structure, and allows early rehabilita- improve this technically demanding procedure. tion with less swelling and pain. Some argue that the real Some researchers, including our team, have reported a advantage of an open approach lies in simultaneous access few minimally invasive techniques to reconstruct lateral to adjacent bones and tendons. Thus, in cases without these ankle ligament. However, these strategies may not always combined lesions, the open approach has no distinctive ben- follow accurate ligament anatomic attachments, especially efits. While compared to arthroscopic reconstruction, with- in the construction of the fibular bone tunnels. Panchbhavi out complex threading and knotting, percutaneous method , Kim et al.  and Youn et al.  made a straight fib- is easily reproducible, timesaving, and its learning curve is ular tunnel in an anterior to posterior or otherwise direction, rapid. Meanwhile, it has the advantage of not preventing the 1 3 1554 Archives of Orthopaedic and Trauma Surgery (2018) 138:1549–1555 3. Xu X, Hu M, Liu J, Zhu Y, Wang B (2014) Minimally invasive use of arthroscopic methods, or open methods, in the case reconstruction of the lateral ankle ligaments using semitendinosus of failure. autograft or tendon allograft. Foot Ankle Int 35:1015–1021 Fixation using the Tightrope in our study is a relatively 4. Snook GA, Chrisman OD, Wilson TC (1985) Long-term results new technique compared with traditional methods. The of the Chrisman–Snook operation for reconstruction of the lateral ligaments of the ankle. J Bone Jt Surg Am 67:1–7 Tightrope device was commonly used to offer cortical 5. Silver CM, Deutsch SD (1982) Evans repair of lateral instability fixation for cruciate ligament reconstruction [25– 27]. This of the ankle. Orthopedics 5:51–56 suture-button system can facilitate folded graft fill of fibu- 6. Gillespie HS, Boucher P (1971) Watson–Jones repair of lateral lar tunnel and offer strong pullout strength. However, this instability of the ankle. J Bone J Surg Am 53:920–924 7. Keller M, Grossman J, Caron M, Mendicino RW (1996) Lat- system is not without its own problems. In our study, two eral ankle instability and the Brostrom–Gould procedure. J Foot patients reported soft tissue irritation from the cortical but- Ankle Surg 35:513–520 ton. No granuloma formation or osteolysis in adjacent bone 8. Gerstner Garces JB (2012) Chronic ankle instability. Foot Ankle occurred in the patients. Clin 17:389–398 9. Hennrikus WL, Mapes RC, Lyons PM, Lapoint JM (1996) This study had several limitations. First, the follow-up Outcomes of the Chrisman–Snook and modified-Brostrom time was relatively short. The outcomes in this study are procedures for chronic lateral ankle instability. A prospective, limited to the early results of treatment of CAI with a Tight- randomized comparison. Am J Sports Med 24:400–404 rope system. We will continue to follow-up these patients. 10. Nery C, Raduan F, Del Buono A, Asaumi ID, Cohen M, Maffulli N (2011) Arthroscopic-assisted Brostrom–Gould for chronic Second, the sample size was small. We are working on treat- ankle instability: a long-term follow-up. Am J Sports Med ing more patients with this procedure. 39(11):2381–2388 11. Xu HX, Lee KB (2016) Modified Brostrom procedure for chronic lateral ankle instability in patients with generalized joint laxity. Am J Sports Med 44:3152–3157 Conclusion 12. Huang B, Kim YT, Kim JU, Shin JH, Park YW, Kim HN (2016) Modified Brostrom procedure for chronic ankle insta- Percutaneous anatomic reconstruction of the lateral liga- bility with generalized joint hypermobility. Am J Sports Med 44:1011–1016 ments of the ankle with a Tightrope system is an anatomic 13. Maffulli N, Del Buono A, Maffulli GD, Oliva F, Testa V, Capasso and effective procedure for the treatment of chronic lateral G, Denaro V (2013) Isolated anterior talofibular ligament Bros- ankle instability. Good to excellent results can be obtained trom repair for chronic lateral ankle instability: 9-year follow-up. surgically with this procedure. It is a good option for CAI in Am J Sports Med 41:858–864 14. Dierckman BD, Ferkel RD (2015) Anatomic reconstruction with a patient meeting our criteria of complex cases. Further stud- a semitendinosus allograft for chronic lateral ankle instability. Am ies are needed with a larger sample size and longer follow-up J Sports Med 43:1941–1950 time. 15. Miyamoto W, Takao M, Yamada K, Matsushita T (2014) Accel- erated versus traditional rehabilitation after anterior talofibular Funding The National Natural Science Foundation of China (no. ligament reconstruction for chronic lateral instability of the ankle 81272051) supports this work. in athletes. Am J Sports Med 42:1441–1447 16. Richter J, Volz R, Immendorfer M, Schulz M (2012) Reconstruc- tion of the lateral ankle ligaments with hamstring tendon autograft Compliance with ethical standards in patients with chronic ankle instability. Oper Orthop Traumatol 24:50–60 Conflict of interest Yongxing Cao, Yang Xu, Yuan Hong, and Xiang- 17. Jung HG, Kim TH, Park JY, Bae EJ (2012) Anatomic reconstruc- yang Xu declare that they have no conflict of interest. tion of the anterior talofibular and calcaneofibular ligaments using a semitendinosus tendon allograft and interference screws. Knee Open Access This article is distributed under the terms of the Crea- Surg Sports Traumatol Arthrosc 20:1432–1437 tive Commons Attribution 4.0 International License (http://creat iveco 18. Ibrahim SA, Hamido F, Al Misfer AK, Ghafar SA, Awad A, Salem mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- H, Alhran H, Khirait S (2011) Anatomical reconstruction of the tion, and reproduction in any medium, provided you give appropriate lateral ligaments using Gracillis tendon in chronic ankle instabil- credit to the original author(s) and the source, provide a link to the ity; a new technique. Foot Ankle Surg 17:239–246 Creative Commons license, and indicate if changes were made. 19. Panchbhavi VK (2011) Minimally invasive allograft lateral ankle ligament reconstruction. Tech Foot Ankle Surg 10:117–121 20. Kim HN, Dong Q, Hong DY, Yoon YH, Park YW (2014) Percuta- neous lateral ankle ligament reconstruction using a split peroneus longus tendon free graft. 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Archives of Orthopaedic and Trauma Surgery – Springer Journals
Published: Jun 6, 2018
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