Ankle Reconstruction with a Free Semi-Tendinosis Graft
abstract & commentary
Synopsis:This retrospective study demonstrates the successful use of a free tendon graft in the treatment of ankle instability in a sports population.
Source: Paterson R, et al. Reconstruction of the lateral ligaments of the ankle using semi-tendinosis graft. Foot Ankle Int 2000;21(5):413-418.
This is a retrospective review of an exciting new avenue in the treatment of ankle instability failing conservative management. A total of 26 athletes (12 males, 14 females) failed initial conservative therapy and underwent a free tendon graft reconstruction of the anterior talofibular ligament (ATFL). The average time between injury and surgery was 23 months (range, 8-60 months) with 73% of patients having undergone more than two months of preoperative physical therapy. Follow-up after the index reconstructive procedure averaged 24 months (range, 13-46 months). Stress radiographs evaluating talar tilt and anterior drawer, range of motion, and balance were measured at follow-up.
Paterson and colleagues used a 4-5 cm oblique incision incorporating a modified Brostrom repair when tissue permitted, and in all patients performed an ATFL reconstruction through 4.5 mm bony tunnels of the fibula and talar neck creating a figure-of-eight construct. The ST tendon was harvested, removing two-thirds of the thickness of the tendon. Postoperative immobilization averaged seven weeks with an average time of return to sport of 12 weeks. Of those tested, 21 of 26 patients (81%) had complete or substantial improvement in instability, swelling, and sharp pain after surgery. Episodes of functional instability persisted in five patients (19%). Radiographic stress examination revealed symmetrical opening on varus tilt and translation on anterior drawer at follow-up. All patients stated they would undergo the surgery again. Kin-Com strength testing was notable for a slight but statistically insignificant decrease in knee flexion strength in 17 patients tested.
Comment by Michael J. Coughlin, MD & Robert C. Schenck, Jr., MD
The use of a free tendon graft has significant advantages in ankle instability surgery. Loss of eversion strength of the ankle with a split brevis graft is a difficult problem created in an attempt to treat the underlying condition. In any reconstructive procedure about the ankle, an anatomic reconstruction of the involved ankle ligaments is necessary. The use of a modified Brostrom procedure underlines this anatomic principle, but in our experience adequate capsular tissue for reefing is frequently lacking. Furthermore, the use of a split peroneus brevis tendon, as noted, decreases eversion strength, but also is frequently inadequate in length characteristics for routing through bone tunnels. Paterson et al should be congratulated on the use of a free tendon graft. However, their failures (as they recognized) were probably related to subtalar instability, and in the senior reviewer’s experience (MJC), simultaneous calcaneo-fibular ligamentous reconstruction is advantageous. In the Idaho experience, a modified Elmslie reconstruction with a free tendon graft treats both the insufficient ATFL and CFL. Lastly, the use of the gracilis tendon is an adequate tissue source leaving the ST tendon intact for potential surgery about the knee. As Paterson et al noted, only two-thirds of the ST was required; and we find the gracilis harvest is less invasive. As hamstring ACL reconstruction is used more frequently in this country, access to this tissue source will become even more popular, with a reconstructive technique that avoids weakening the much needed ankle evertors.
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