Emerging Concepts In Anatomic Repair Of The Lateral Ankle Ligament Complex

With recent advances in tissue engineering, biologic scaffolds have gained increasing popularity for the repair and reconstruction of soft tissues in the foot and ankle. These grafts possess an inherent tensile strength, which supports suture retention and mechanical reinforcement while also providing a three-dimensional scaffold for cellular repopulation.^1-6
We will review the surgical treatment options for chronic ankle instability and describe an anatomic reconstruction of the anterior talofibular ligament and calcaneofibular ligament using an acellular dermal matrix and interference screws.

Ankle sprains are among the most common musculoskeletal injuries.⁷ The majority of ankle sprains involve the lateral ankle ligaments, specifically the anterior talofibular ligament and calcaneofibular ligament.⁸ While conservative treatments are often successful, 20 to 40 percent of patients develop mechanical insufficiencies, which can result in chronic ankle instability.⁹ When instability and pain persist despite conservative measures, surgery is often indicated.

Researchers have described over 50 lateral ankle ligament repair procedures with success rates ranging from 80 to 90 percent.¹⁰ Regardless of procedure selection, the end goal is the same: restoration of the ligament complex, including normal anatomy and stability of the ankle and subtalar joints.^11,12

A Closer Look At Non-Anatomic Procedures
Non-anatomic procedures aim to reconstruct the lateral ankle ligaments and obtain stability without repairing the ligaments directly.^12,13 These reconstructions typically involve the rerouting of the nearby peroneus brevis tendon, the extensor digitorum brevis tendon or the extensor digitorum longus tendon. However, surgeons may also perform these procedures with a harvested tendon, such as the semitendinosus, gracilis, plantaris, palmaris or fascia lata.¹² Examples of non-anatomic lateral ankle reconstructive procedures include the Chrisman-Snook procedure, the Watson-Jones procedure and the Evans reconstruction, all utilizing the neighboring peroneus brevis tendon for augmentation. Use of the peroneus brevis tendon is advantageous because it provides a healthy tendon with adequate strength. However, this sacrifices the strongest evertor of the foot, which can lead to gait instability and thus may not be in the best interests of the patient.^14-16

Non-anatomic procedures attempt to increase the stability of an otherwise unstable ankle by “creating restraints to abnormal motion by positioning graft material perpendicular to the perceived instability.”⁹ However, the outcomes associated with non-anatomic procedures have proven less successful in comparison with anatomic procedures in regard to persistent instability, restoration of normal gait kinematics and restriction of motion, especially at the subtalar joint.^13,15-19

Non-anatomic procedures have also been associated with postoperative cutaneous nerve injuries and degenerative joint disease, secondary to postoperative motion restriction.^17,19 Additionally, non-anatomic procedures require autograft procurement, which can require a second surgical site, introduce the risk of donor site morbidity and increase operation time.²⁰ Given these limitations, anatomic procedures are often appropriate.

What Are The Advantages Of Anatomic Procedures?
Anatomic procedures restore the normal anatomy of the lateral ankle ligaments. In comparison to non-anatomic procedures, anatomic procedures reportedly have lower complication rates, including fewer wounds, less damage to the superficial peroneal nerve and a decreased incidence of long-term degenerative joint disease.^18,21 Moreover, anatomic procedures have little to no effect on subtalar joint motion and promote an earlier return to activity in comparison with non-anatomic procedures.^18,21

We can further classify anatomic procedures as anatomic repairs or anatomic reconstructions. Anatomic repairs involve direct stabilization of the native ligaments. The Broström and the “modified Broström” are the most widely used procedures for anatomic repair of the lateral ankle ligament complex.¹⁰ However, patients’ local tissues often demonstrate insufficiency, lacking adequate substance for direct repair. In these instances, one should consider alternative procedures such as anatomic and non-anatomic reconstruction.

Surgeons should reserve anatomic reconstruction for patients who demonstrate inadequate ligament length, girth or strength for direct repair.²² With insufficient soft tissues, one can use a biologic scaffold to reinforce the attenuated ligament along its normal anatomical course. With advances in tissue engineering, a multitude of augmentation materials have become available for reconstruction supplementation.

Biologic scaffolds are extractions of animal tissues, such as porcine and bovine tissues, as well as human cadaveric tissue. Regenerative tissue matrices also originate from synthetic and chemical constructs.²³ Authors have advocated synthetic scaffolds for their mechanical strength but allografts and xenografts have shown superior graft-host interactions as evidenced by greater graft incorporation.^22,24 Given the variation in augmentation materials, the surgeon should be familiar with the specific graft characteristics (e.g. source, cellular or acellular, and processing methods) prior to surgical application.

Performing Anatomic Reconstruction Using A Biologic Scaffold
Our preferred surgical technique is an anatomic reconstruction and involves the direct recreation of the anterior talofibular ligament and calcaneofibular ligament using a biologic scaffold to create a stable construct.

We favor an acellular matrix derived from human tissue that closely resembles the anatomic thickness of the native anterior talofibular ligament and calcaneofibular ligament (GraftJacket MaxStrip, Wright Medical Technology). Notably, the allograft retains its native extracellular matrix proteins in cell-friendly forms while maintaining biocompatibility.²⁵ Researchers believe this allogeneic graft promotes nutritional diffusion, cellular repopulation, rapid revascularization and stability with no evidence of graft rejection.^26,27 Given its ability “... to enhance initial repair strength as well as (facilitate) healing via a scaffold effect,” physicians have employed this graft in a multitude of surgical procedures.^1,28-38

Key Insights On Surgical Technique
Make an 8 cm curvilinear incision along the anterior border of the fibula, extending it distally to the talar neck. Evaluate the anterior talofibular ligament and calcaneofibular ligament to confirm attenuation. After confirmation, prepare the talar neck for placement of a lateral to medial interference screw. Tag a 12 cm x 1 cm x 1.5 mm tissue matrix allograft at one end with 2-0 Ethibond (Ethicon). Pass the tagged end through the talar neck from lateral to medial and secure it into place with a non-absorbable polyetheretherketone interference screw.

Proceed to prepare the distal fibula for the placement of a posterior to anterior interference screw. Pull the allograft through the fibular channel, place the newly created anterior talofibular ligament under appropriate physiologic tension and implant a second non-absorbable interference screw. Access the lateral calcaneus through a percutaneous incision and prepare the calcaneus for placement of a medial to lateral interference screw.

After this preparation, pass the allograft subcutaneously from the primary incision to the calcaneal incision. Tag the free end of the allograft with 2-0 Ethibond. Then pass the tagged end through the calcaneus from lateral to medial and secure it in place with a third non-absorbable interference screw under appropriate physiologic tension. The patient wears a non-weightbearing posterior splint for eight weeks.

In Conclusion
At present, there is a paucity of research regarding the use of biologic scaffolds to supplement ligament repair in the foot and ankle. The available data is primarily limited to retrospective case series and case reports reviewing the reconstruction of tendons, namely the Achilles tendon.^4,38-42 In 2011, however, Jung and colleagues described a similar technique for the reconstruction of the anterior talofibular ligament and calcaneofibular ligament using a semitendinosus allograft.³⁸ Notably, 80 percent of patients achieved good to excellent results.

Moving forward, a long-term prospective study with a larger sample size is necessary to fully evaluate the effectiveness of biologic scaffolds in the reconstruction of the lateral ankle ligament complex.
When the lateral ankle ligaments are inadequate for direct repair, one should consider augmentation with a biologic scaffold as it permits anatomic reconstruction and is capable of restoring normal anatomy, kinematics and function.^38,43,44 Additionally, this technique avoids autograft harvest and the use of an allograft tendon eliminates the risk of disease transmission.

In our experience, direct anatomic reconstruction of the anterior talofibular ligament and calcaneofibular ligament using an allograft tissue matrix and interference screws provides a viable option for the surgical treatment of severe lateral ankle instability in patients who have failed conservative therapy. While this procedure is more technically challenging in comparison to the Broström procedure, it successfully reinforces inadequate soft tissues and restores anatomic tissue location.

Dr. Mulhern is a Fellow of Foot and Ankle Reconstruction at Coordinated Health in Bethlehem, Pa. She is an Associate of the American College of Foot and Ankle Surgeons.

Mrs. Protzman is a Research Associate at Coordinated Health in Allentown, Pa.

Dr. Brigido is the Fellowship Director of Foot and Ankle Reconstruction at Coordinated Health in Bethlehem, Pa. He is a Fellow of the American College of Foot and Ankle Surgeons.

The authors would like to thank Melissa M. Galli, DPM, MHA, AACFAS, and Scott T. Bleazey, DPM, AACFAS for their contribution to the manuscript.

Dr. Galli is Fellowship Trained in Foot and Ankle Reconstruction at Coordinated Health in Bethlehem, Pa. She is an Associate of the American College of Foot and Ankle Surgeons. She is an Attending Physician at the CORE Institute in Phoenix.

Dr. Bleazey is Fellowship Trained in Foot and Ankle Reconstruction at Coordinated Health in Bethlehem, Pa. He is an Associate of the American College of Foot and Ankle Surgeons. He is an Attending Physician at Somerset Orthopedic Associates in Bridgewater, NJ.
 
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