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Lateral Ligament Reconstruction With Tendon Graft

Indication

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. 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.

Procedure

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. 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. 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 the potential for “overtightening” of the ankle.

Recovery

Recovery from a non-anatomic ankle ligament reconstruction relative immobilization and considerable activity limitations for a period of 6 to 12 weeks. Patients are typically using crutches or a walker, and immobilized in a cast or boot. Participation in physical therapy during the recovery phase is important. 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 take 6-12 months before they reach their maximal improvement as regaining lost strength and flexibility can take a long time. A brace or ankle sleeve is often needed to support the ankle for 6 to 12 months post-op until the patient’s confidence in their ankle 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 by local scar tissue which can lead to short term numbness and tingling. This can require more involved physical therapy to free up the local scar tissue and “desensitize” the involved nerve. 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 tendon is unusual but can occur. Typically this is because the tissue stretches over time during the healing process as the body incorporates the graft and the repair is repetitively load via walking and other activities.
  • 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.
  • Persistent ankle pain unrelated to ankle instability: Having an unstable ankle that gives way leads to repetitive ankle sprains whihc can be painful. However, ankle pain in the setting of ankle instability is often not from the instability itself, but rather from some other cause such as a talar osteochondral lession, peroneal tendonitis, or ankle arthritis. If this is the case surgery to stabilize the lateral ankle ligaments will not relieve all of a patient’s ankle symptoms.

Patients undergoing any type of lateral ligament stabilization surgery are subject to the potential for the usual risks associated with any orthopaedic surgery procedure such as the risk of:

Outcomes

When appropriately performed, non-anatomic ankle ligament reconstructions are highly successful in obtaining a stable ankle.

Edited on September 16th, 2023
Previously edited by Eric Malicky, MD , Paul Juliano, MD, Anthony Van Bergeyk, MD and Robert Leland, MD)

sp/9.16.23

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