Anatomical vs. Peroneal Tendon Reconstructions for Chronic Ankle Instability
Abstract & commentary
Synopsis: Anatomical reconstructions were superior to a tenodesis procedure using clinical, functional, and mechanical criteria.
Source: Krips R, et al. Anatomical reconstruction vs. tenodesis for the treatment of chronic anterolateral instability of the ankle joint: A 2- to-10-year follow-up, multicenter study. Knee Surg Sports Traumatol Arthrosc 2000;8:173-179.
This is a retrospective, multicenter study with medium- to long-term follow-up comparing anatomical reconstruction procedures (Imbrication or Brostrom) with peroneal tendon re-routing procedures (tenodesis) (Evans, Watson-Jones, Chrisman-Snook, etc). Entry criteria included at least six months of recurrent ankle instability refractory to rehabilitation, no other history of ankle injuries, and a normal contralateral ankle. A total of 324 procedures were performed at five European centers over a nine-year period (1987-1995). Of these procedures, 152 were anatomical and 172 used peroneal tendons. The procedures were not randomized, and a variety of tenodesis procedures were performed. Approximately two-thirds of the patients were evaluated at 2-10 years. Of these, 106 were in the anatomical group and 110 in the tenodesis group. The groups were not significantly different with regard to age, sex, dominant side, activity level, or mean follow-up. Two ankle scoring systems (Karlsson and Good) were used. Range of motion (ROM), plain radiography (degenerative changes), and stress radiography were recorded for all patients at follow-up. Significant differences were demonstrated in the number of good/excellent results (Good score), ROM, stability on stress radiography, and number of reoperations—all favoring the anatomical reconstructions.
Comment by Mark Miller, MD
This study suffers from several inherent flaws: It is retrospective, non randomized, and involves several different tenodesis procedures. Nevertheless, it does provide mid- to long-term follow-up of procedures that are commonly done in the community. There has been a recent increase in the popularity of "anatomic" or imbrication procedures, both in Europe and in the United States. Perhaps this is because many of us have experienced anecdotally what this study has attempted to objectively evaluate. One axiom in orthopaedics is continually borne out—anatomical procedures are better. This is true not only in the ankle, but in several other joints as well (e.g., the shoulder-labral repair and capsular shift, knee-cruciate and collateral reconstructions, and elbow-collateral ligament reconstructions). Tenodesis procedures or transfers, even when designed to reproduce the normal anatomy, tend to restrict motion, decrease eversion strength, and stretch out over time. A randomized, prospective study with more closely defined groups is needed to provide the final answer to this issue. However, the present study certainly favors anatomical procedures.
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