Chronic lateral ankle instability

 

talar tiltCFLBrostrom

 

Definition

 

Chronic instability due to rupture of one or more of the lateral ankle ligament

 

Recurrence risk

 

Incidence

 

van Rijn et al Am J Med 2008

- sytematic review of 31 studies

- up to 33% patients still have pain 1 year after acute ankle sprain

- up to 34% risk of recurrent ankle sprain

 

Factors

 

Thompson et al BMC Musculoskeletal Disord 2017

- prognostic factors associated with poor recovery after acute ankle sprain

- female, increased severity of initial injury

- pain at 3 months, resprain within 3 months

- increase number of ligament injuries + bone bruise on MRI

 

Osteoarthritis

 

Lofenberg et al Foot Ankle Int 1994

- patients with chronic ankle instability at 20 year follow up

- 6/46 (13%) had OA on xrays

 

Ankle OA Post Lateral Ligament Instability

 

History

 

Swelling

 

Instability - giving way with activity & walking on uneven ground

 

Chronic pain is unusual with isolated chronic instability

- osteochondral fracture / injury

- syndesmosis injury

- lateral talar process / anterior calcaneal process fracture

- peroneal tendonitis / subluxation / dislocation

- sinus tarsi syndrome

 

Examination

 

Anterior drawer  Talar tilt
Assess ATLF CFL test / subtalar instability

10° plantarflexion neutral rotation

Draw talus anterior to tibia

10-20° plantarflexion

Ankle inversion

> 3mm difference to other ankle > 20o difference to other ankle
Ankle Anterior Drawer Talar Tilt

 

Xrays

 

Osteochondral lesions

 

Talus OCD Anterolateral 2

 

Loose bodies

 

LBLB

 

Stress Xrays

 

Anterior drawer  Talar tilt
Assess ATLF CFL test / subtalar instability

10° plantarflexion neutral rotation

Draw talus anterior to tibia

10-20° plantarflexion

Ankle inversion

> 3mm difference to other ankle > 20o difference to other ankle
Ankle stress Ankle stress

 

MRI

 

CFL CFLATFLTear ATFL

ATFL tear

 

ATFLATFLTear ATFLATFL

ATFL tear

 

CFLCFLCFL tearCFL

CFL tear

 

Management

 

Non-operative 

 

Bracing / taping

 

Biz et al Medicina 2022

- systematic review of effect of kinesio taping for chronic ankle instability

- evidence for gait improvement and reduced inversion/eversion

 

Rehabilitation exercises

 

Neuromuscular training / proprioception / balance / strengthening

 

Tsikopoulos et al CORR 2018

- systematic review of multimodal rehabilation for chronic ankle instability

- evidence of efficacy of 4 week programs

 

Operative Management

 

Indication

 

Ongoing instability

 

Options

 

Anatomic repair - modified Brostrom

Anatomic reconstruction - autograft / allograft reconstruction ATFL / CLF

Non anatomic reconstruction - peroneus brevis tenodesis

 

Results

 

Vopat et al Arthros Sports Med Rehab 2022

- systematic review of repair versus reconstruction versus suture tape augmentation

- 41 studies and 2000 patients

- complication rate: reconstruction 3%, repair 4%, suture tape 11%

- no difference functional outcomes

 

Anatomic Repair / Modified Brostrom

 

Concept

 

Mid substance repair / bony repair

Gould Modification - reinforce ATFL repair with extensor retinaculum

 

Options

 

Internal brace / suture tape augmentation

Arthroscopic techniques

Augmentation with non anatomic / peroneus brevis reconstruction

 

Open technique

 

Arthrex modified Brostrom surgical technique video

 

Vumedi open modified Brostrom video

 

Longitudinal incision anterior to lateral malleolus

- protect branches of superficial peroneal nerve

- expose tissue of ATFL / CFL

- anterior incision between ATFL and CFL to talus

- begins at tip of fibula to talus

- take off fibula as broad / thick flap

- superior flap is ATFL / inferior flap is CFL

- need to protect peroneals with inferior portion of dissection

- inspect talus for chondral damage

 

IncisionLateral Ligament Repair Flap IncisionsFirst Transverse IncisionInferior CFL Flap

 

Place foot in eversion and AJ neutral

- 2 x 3.5 mm anchors in fibula

- ensure not in joint and not prominent

- 4 sutures through ATFL

- 2 through CFL

- 2 sutures either side of interval of ATFL and CFL

 

ATFL FlapAnterior Anchor2 Sutures Inferior Flap2 Sutures to Close Interval

 

Gould modification

- inferior extensor retinaculum anatomy laterally arises from anterior surface calcaneum

- medially has 2 limbs - med malleolus & plantar aponeurosis

- advance the inferior retinaculum and suture to the fibular to reinforce the repair

 

BrostromBrostrom

 

Results

 

Ligamentous laxity

 

Park et al AJSM 2016

- 199 ankles with mean 5 year follow up

- modified Brostrom

- clinical failure non ligament lax: 11%

- clinical failure ligament lax: 45%

- ligamentous lax / talar tilt > 15 / anterior displacement > 10 mm / syndesmotic widening / OC lesion

 

Postoperative weight bearing

 

Vopat et al Orthop J Sports Med 2020

- systematic review of early versus delayed weightbearing after lateral ligament repair

- 28 studies and 1500 patients

- early weight bearing higher functional outcome scores

- early weight bearing increased objective laxity and outcomes

 

Suture tape augmentation / internal brace

 

Internal brace

Arthrex

 

Technique

 

Arthrex internal brace ankle ligament repair PDF

 

Arthroscopic techniques internal brace ankle ligament repair PDF

 

Results

 

Mercer et al Orthop J Sports Med 2022

- systematic review of suture tape augmentation compared to primary repair

- no difference in outcomes

- no evidence to recommend additional suture tape augmentation

 

Arthroscopic techniques

 

Technique

 

Vumedi arthroscopic ligament repair video

 

Arthroscopic ligament repair surgical technique PDF

 

Arthroscopic ligament repair + suture tape augmentation PDF

 

Results

 

Attia et al Orthop J Sports Med 2021

- systematic review of open versus arthroscopic repair

- 8 studies and 400 patients

- superior outcome scores with arthroscopic

- no difference in objective stability

 

Anatomic reconstruction

 

Options

 

Autograft

Allograft

Suture tape / LARS ligament

 

Technique

 

Arthrex anatomic reconstruction surgical technique video

 

Arthroscopic ATLF reconstruction technique PDF

 

reconAnkle recon

Arthrex

 

Results

 

Li et AJSM 2024

- systematic review of return to sports after anatomic ankle ligament reconstruction

- 25 studies with 1400 patients

- 95% return to any sport

- 83% return to previous sport

- 87% return to competitive sport

- mean time 12 weeks

 

Porter et al AJSM 2019

- RCT of anatomic reconstruction with LARS v modified Brostrom

- 41 patients with 2 year follow up

- improved outcomes and reduced failure with LARS

 

Non anatomic reconstruction

 

Indications

 

Poor tissue for anatomic repair

Hypermobile STJ / ligamentous laxity

Revision

 

Issue

 

Limited movement of subtalar joint

Osteoarthritis

 

Evans Watson-Jones Chrisman-Snook
Tenodesis of Peroneus brevis

Split peroneus brevis

Split peroneus brevis

Divide Peroneus brevis proximally

Pass through fibular tunnel

 

Split Peroneus brevis in two

Leave attached to base 5th metatarsal

Divide proximally

Pass through fibula posterior to anterior

Pass into drill hole in talar neck
 

Split Peroneus brevis in two

Leave attached to base 5th metatarsal

Divide proximally

Pass through fibula anterior to posterior

Pass into drill hole in calcaneus

2 3 1

 

Results

 

Larsen et al CORR 1990

- RCT of static versus dynamic reconstruction using peroneus brevis

- increased satisfaction with static reconstruction

- reduced recurrence with dynamic reconstruction