Surgical Interventions in Ankle Sprain 

Updated: Aug 03, 2017
  • Author: Vinod K Panchbhavi, MD, FACS; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
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Indications for Surgical Intervention

Distal tibiofibular ligament sprain with widened ankle mortise

One of the few absolute indications for surgery in patients with a high ankle sprain involving the distal tibiofibular ligament is a third-degree sprain that causes widening or a diastasis of the syndesmosis between the distal fibula and tibia. To restore the ankle mortise, the distal tibiofibular articulation must be brought together with implants, such as screws or synthetic sutures over endobuttons.

The usual postoperative course entails initial protection in a splint, wound check and further protection in a cast, and avoidance of weightbearing for 6 weeks, followed by physical therapy and gradual return to normal activities.

Lateral ankle ligament sprains

It is generally accepted that for most patients, operative repair of third-degree anterior talofibular ligament (ATFL) tears and medial ankle ligament tears does not contribute to an improved outcome. [1]

In 100 patients with isolated lateral ligament sprains, Evans et al found no functional or symptomatic advantage 2 years after injury in patients who were treated surgically as compared with those who were treated with cast immobilization. [2] In fact, the nonsurgically treated group returned to work earlier and had less morbidity than the surgically treated patients. Patients in this study were divided into two groups, each with 30 individuals with anterior ligament sprains only and 20 individuals with anterior and middle ligament ruptures. One group of 50 patients was treated surgically, and the other group was treated with cast immobilization.

Double lateral ligament tears

Staples reported that young, active, athletic patients with tears of both the ATFL and the calcaneofibular ligament (CFL) are best treated surgically. His cohorts included a group of young athletic patients with only 58% satisfactory results after immobilization and a subsequent, similar group of patients who had 88.9% satisfactory results with surgical repair. In the group of patients who underwent surgery, the average hospital stay was 7.6 days, and six (22.2%) of 27 patients had complications. Marginal necrosis of the skin at the wound edge and hypesthesia of the fourth and fifth toes and adjacent forepart of the foot were the only reported complications. [3]

Entrapped deltoid ligament

An isolated complete medial ankle sprain with a palpable defect and demonstrable clinical instability is an indication for surgery, particularly if the deltoid ligament is caught in the medial ankle joint. Surgery allows removal of the ligament from the joint and repair of the ligament.

Go to Ankle Sprain for more complete information on this topic.

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Surgery for Chronic Ankle Instability

Selection of operative approach

According to a review by Safran et al, more than 20 different delayed surgical procedures are available for chronic ankle instability and sprains. [4] These are classified as either anatomic or nonanatomic. Anatomic repairs use the native tissues, reinforce the existing ligaments, or both. Most of the nonanatomic repair  procedures are reconstructive in nature and involve tenodesis between the lateral malleolus and calcaneus, talar head, or the fifth metatarsal.

Some of these procedures use the peroneus brevis or longus as autograft and are routed through bone tunnels to provide lateral ankle stability. Use of the local tendons in a nonanatomic manner affects the normal biomechanics of the hindfoot in addition to donor tendon morbidity due to the loss of function from tendon that is sacrificed. If the tissues are of good quality, a direct repair of the ligaments can be performed; if the tissues are of poor quality, autograft or allograft tendons are used.

For syndesmotic sprains, surgical treatment depends on whether any arthritic change is present. If the articular surface is destroyed on both sides of the joint, tibiotalar arthrodesis or arthroplasty is necessary. In patients with diastasis without significant tibiotalar arthritis, late reduction of the syndesmosis and reconstruction of the ligaments are recommended. [5]

Broström procedure

Broström described a repair that reapproximates the ruptured ligaments and restores true normal anatomy of the ankle. Gould et al described a modified Broström procedure that allowed reinforcement of the repair and limited inversion (reducing the likelihood of injury) and that helped to correct the subtalar component to the instability. [6] This modified procedure permitted restoration of the normal anatomy and preserved normal ankle motion with less surgical exposure.

In Gould's procedure, the incision is performed from an anterolateral approach, paralleling the fibula border, and starting from the level of the plafond distally to the level of the peroneal tendons. Dissection is then carried down to the capsule. If no obvious ATFL rupture is present, the capsule and ligaments are divided for a few millimeters and then imbricated. [6, 7, 8]  (See the images below.)

Brostrom-Gould repair. Instrument under anterior t Brostrom-Gould repair. Instrument under anterior talofibular ligament (ATFL).
Brostrom-Gould repair. Transected anterior talofib Brostrom-Gould repair. Transected anterior talofibular ligament (ATFL).
Brostrom-Gould repair. Avulsed fibular bony fragme Brostrom-Gould repair. Avulsed fibular bony fragment.
Brostrom-Gould repair. Excision of avulsed fibular Brostrom-Gould repair. Excision of avulsed fibular bony fragment.
Brostrom-Gould repair. Reflected proximal flap of Brostrom-Gould repair. Reflected proximal flap of anterior talofibular ligament (ATFL), cancellous bed at distal end of fibula, and sutures coming out distal flap from embedded suture anchors to help advance distal flap of transected ATFL.
Brostrom-Gould repair. Double-breasted anterior ta Brostrom-Gould repair. Double-breasted anterior talofibular ligament (ATFL) with proximal flap overlying distal flap.
Brostrom-Gould repair. Incorporation of extensor r Brostrom-Gould repair. Incorporation of extensor retinaculum in suture for advancement of retinaculum over repaired anterior talofibular ligament (ATFL).

The peroneal sheath is then opened to determine the quality of the CFL. If the CFL is stretched, it can be divided and imbricated. [6] If this ligament is ruptured, a distal avulsion from the calcaneus can be reattached with a suture anchor. A proximal avulsion can be reattached with sutures through drill holes in the fibula. [6]

Attenuation or failure of previously repaired ligaments in case of recurrent laxity necessitates augmentation with auto- or allograft, in that the local tissue is frequently of insufficient quality. Furthermore, failed surgical repair may be associated with previous surgical scars and compromised local skin and subcutaneous tissues.

Minimally invasive reconstruction of lateral ankle ligaments is an attractive option that avoids long exposures and scars and minimizes the risks of wound or flap failure, especially in patients with previous scars or poor soft tissues. In 2011, the author published a minimally invasive technique in which allograft was used to reconstruct lateral ankle ligaments in the presence of scarring or revision surgery where the ligament tissue quality was poor. [9]  (See the images below.) 

Minimally invasive allograft reconstruction of lat Minimally invasive allograft reconstruction of lateral ankle ligament. View post calcaneal osteotomy showing patient positioning and scar from previous failed lateral ankle ligament repair.
Minimally invasive allograft reconstruction of lat Minimally invasive allograft reconstruction of lateral ankle ligament. Percutaneous exposure for graft insertion using biotenodesis screw into talus and allograft routed distally.
Minimally invasive allograft reconstruction of lat Minimally invasive allograft reconstruction of lateral ankle ligament. Talar tunnel.
Minimally invasive allograft reconstruction of lat Minimally invasive allograft reconstruction of lateral ankle ligament. Fibular tunnel.
Minimally invasive allograft reconstruction of lat Minimally invasive allograft reconstruction of lateral ankle ligament. Postoperative scars from percutaneous routing of allograft tendon.

An arthroscopic variant of the Broström procedure has been described. [10]

Tenodesis procedures

Other surgical options, as mentioned above, are mainly tenodesis procedures, of which the following four have been extensively used and described in the literature:

  • Evans procedure
  • Watson-Jones procedure
  • Larsen procedure
  • Chrisman-Snook procedure

These procedures focus on harvesting all or part of the peroneus brevis and then rerouting the tendon through various bone tunnels, thereby creating a tenodesis of the ankle or reconstructing the ATFL or the CFL. Indications for these augmented types of reconstruction are as follows:

  • The ATFL and CFL are so disrupted and frayed that they cannot be repaired primarily
  • Hypermobility of the subtalar joint is present
  • The patient has had previously unsuccessful reconstruction of the ankle

For each of these procedures, the overall technical approach is essentially the same. A longitudinal incision is made running just posterior to the prominence of the lateral malleolus. The incision is then extended to allow harvesting of the peroneus brevis tendon. Before harvesting the tendon, the joint is inspected and debrided if necessary. Occasionally, the ATFL, the CFL, or both are avulsed from the fibula with a piece of bone. This so-called os subfibulare should be excised.

The integrity of the superior peroneal retinaculum should be maintained during exposure of the peroneus brevis tendon. The anterior one third of the tendon is isolated distally and split from the distal position to the musculoskeletal junction. This tendon portion is transected at its proximal aspect. A drill hole is made through the distal fibula, and the split portion of the peroneus brevis is passed through this hole. The tendon is tensioned with the foot in mild plantarflexion and eversion.

Because the peroneus brevis tendon is anchored to the fibula, the Evans reconstruction indirectly limits inversion of the ankle and anterior talar translation while also limiting motion of the subtalar joint. This procedure provides stability in a location that lies between the ATFL and CFL; therefore, it does not restore the anatomy or biomechanics of the hindfoot.

The Watson-Jones procedure reconstructs the ATFL but not the CFL. This technique makes use of the Evans tenodesis. One important addition, however, is that the peroneus brevis graft is routed anteriorly through the talar neck to reconstruct the ATFL.

Larsen rerouted the peroneus brevis tendon from the fifth metatarsal base into the fibula and then back down into the calcaneus. The proximal part of the tendon is sutured to the peroneus longus. [11]

The Chrisman-Snook procedure, most commonly used for subtalar instability, involves using half of the longitudinally divided peroneus brevis tendon to substitute for or reconstruct the CFL. In this procedure, the peroneus brevis graft is brought through the fibula from anterior to posterior to reconstruct the ATFL. It is then brought posteriorly and inferiorly to the calcaneus in a weave pattern to reconstruct the CFL. This procedure, though technically demanding, has been repeatedly demonstrated to produce satisfactory stability in patients with talotibial and combined talotibial and talocalcaneal instability.

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Outcomes of Operative Repair

Most of the nonanatomic procedures are now considered to be of historical interest only, having been superseded by anatomic repairs that use either native ligaments or allograft tendons.

In the literature, the Watson-Jones procedure was associated with subjective instability 20-90% of the time; the Evans procedure, 20-33%. In addition, with the Evans procedure, a persistent anterior drawer sign was found in 45-60% of patients. In the Chrisman-Snook procedure, 13-30% of patients had subjective persistent instability. Decreased inversion is common with all these procedures. In each procedure, a specific weave pattern (referring to the manner in which the peroneus brevis tendon is routed through the drill holes) is used.

In a study by Kim et al, chronic syndesmotic instability and chronic medial ankle instability were found to be significantly associated with unsatisfactory outcomes in patients with chronic ankle instability who had undergone treatment with a modified Broström procedure. [12]

Park et al, in a study of the use of the anterior half of the peroneus longus tendon (AHPLT) as an autograft for lateral ankle ligament reconstruction in 31 cases, reported good clinical and radiographic results at a minimum 1-year follow-up, without a significant decrease in peroneus longus strength. [13]

Matheny et al compared outcomes and revision rates after Broström-Gould lateral ankle ligament repair with those after anatomic allograft reconstruction in 86 patients with lateral ankle instability. [14] At an average follow-up of 3.0 years, no patient in either cohort underwent revision lateral ligament surgery. The authors concluded that anatomic allograft reconstruction, as compared with lateral ankle repair, produced similarly favorable outcomes, including high patient satisfaction, high function and activity levels, and no need for surgical revision.

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