Lateral Ligament Reconstruction With Tendon Graft
Edited by Eric Malicky, MD
Lateral ankle instability can be treated surgically, either with tightening of the existing ligaments (anatomic repair, example: Brostrom procedure) or a lateral ankle ligament reconstruction using a tendon graft (See Figure #1). While it is often the preference of the surgeon that determines which of these surgeries is performed, some general guidelines may influence the decision. A previous failure of an ankle ligament stabilization procedure may be an indication for a reconstruction using a tendon graft. Others feel that tendon graft reconstruction is best even for first time procedures, due to inherent weakness in the scar tissue left after damaging the ligaments.
Tendon reconstruction of the lateral ankle ligaments involves stabilizing the stretched out dysfunctional ankle ligaments (anterior talofibular and calcaneofibular ligaments) by weaving a tendon graft through bone tunnels. The tendon graft re-creates the distribution of the existing injured ankle ligaments (see Figure 1). This is performed using either: a portion of the patient’s own tendon (autograft) or from a sterile cadaver (allograft). The tendon graft is weaved through bone tunnels in the lateral ankle using a variety of techniques. In each case, the tendon is tensioned and secured into bone (see Figure 2). Through the non-anatomic ankle ligament repair, the graft is used to substitute for the patient’s injured ligaments and stabilize the ankle. The main criticism of the non-anatomic ankle ligament repair is “overtightening” of the ankle.
Recovery from a non-anatomic ankle ligament reconstruction spans 6 to 12 weeks. Patients are typically using crutches or a walker, immobilized in a cast or boot and participate in physical therapy. Physical therapy focuses on the following:
- Improving ankle motion
- Strengthening the ankle and leg muscles
- Improve balance and coordination (proprioception)
- Restore normal gait and athletic performance
Patients will often need a brace or ankle sleeve for 6 to 12 months post-op until their confidence is fully restored.
Potential Complications of the Surgery
There are some potential risks of surgery that are specific to lateral ligament reconstruction procedures. These include:
- Injury to the superficial peroneal or sural nerve: These nerves are rarely injured but if so, there are treatments. If the nerve is cut, there would be numbness around the area and at times nerve pain. More often, the nerves are stretched or irritated which can lead to short term numbness and tingling. Most nerve issues settle within 6 months to 1 year of the surgery.
- Overtightening of the ankle joint: This is the most common criticism of a non-anatomic ankle ligament reconstruction since the tendon graft can stiffen the ankle and subtalar joints. Unfortunately, some patients may even develop arthritis related to the overly tight joint over time. For this reason, the anatomic ankle ligament repair (Brostrom procedure) continues to remain the preferred approach for most ankle injuries.
- Stretching out of the tendon reconstruction: The failure of the autograft/allograft tenon is unusual but can occur. Typically this is because the tissue stretches overtime during the healing process as the body incorporates the graft.
- Suture or hardware irritation beneath the skin: The suture and hardware used to fix the tendon to the bone can occasionally be felt beneath the skin. If retained hardware becomes painful or irritating, this can many times be removed but this is rarely required.
Patients undergoing the surgery are subject to the potential for the usual risks associated with surgery such as the risk of:
- Wound healing problems
- Nerve Injury
- Deep Vein Thrombosis (DVT)
- Pulmonary Embolism (PE)
- Ankle pain unrelated to instability
When appropriately performed, non-anatomic ankle ligament reconstructions are highly successful in obtaining a stable ankle.