Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-015-3789-z

ANKLE

Arthroscopic anatomical reconstruction of the lateral ankle ligaments S. Guillo1 · M. Takao2 · J. Calder3,4 · Jon Karlson5 · Frederick Michels6 · Thomas Bauer7 · Ankle Instability Group

Received: 19 January 2015 / Accepted: 10 September 2015 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015

Abstract  Chronic ankle instability secondary to lateral ligament insufficiency is common after sports injury. Many surgical techniques have been described for the treatment of the lateral ankle ligament complex. They can be classified into repair or reconstruction, and nonanatomical or anatomical. A few authors have recently published innovative techniques for arthroscopic ankle ligament management. This paper describes the arthroscopic techniques enabling anatomical lateral ligament reconstruction using gracilis autograft or allograft for chronic ankle instability. This technique and the steps Ankle Instability Group members are as follows: T. Bauer, J. Calder, N. M. Corte-Real, M. Glazebrook, S. Guillo, J. Karlsson, J. G. Kennedy, S. W. Kong, P. G. Mangone, F. Michels, A. Molloy, C. Nery, C. Pearce, A. Perera, H. Pereira, B. Pinenburg, F. Raduan, J. W. Stone, M. Takao, Y. Tourné, J. W. Lee. * S. Guillo [email protected] 1

Clinique du Sport, 2 rue Negrevergne, 33700 Bordeaux‑Mérignac, France

2

Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2‑11‑1 Kaga, Itabashi, Tokyo 173‑8605, Japan

3

Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK

4

The Fortius Clinic, 17 Fitzhardinge St, London W1H 6EQ, UK

5

Department of Orthopaedics, Hospital, Sahlgrenska University, Göteborg, Sweden

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Orthopaedic Department, AZ Groeninge Burg, Vercruysselaan 5, 8500 Kortrijk, Belgium

7

Hopital Ambroise Paré, 9 Avenue Charles de Gaulle, 92100 Boulogne‑Billancourt, France





have been developed by the Ankle Instability Group to make this a reproducible procedure. The purpose of this presentation is to document the technique in the future with a view to a clinical study investigating the results of such surgery in a cohort of suitable patients with chronic ankle instability. Level of evidence V. Keywords  Hindfoot endoscopy · Ankle arthroscopy · Ankle instability · Ankle ligament reconstruction

Introduction Chronic ankle instability secondary to lateral ligament insufficiency is common after sports injury. Many surgical techniques have been described for stabilizing the lateral ankle ligament complex. They can be classified into: repair and non-anatomical reconstruction or anatomical reconstruction [4, 9]. Excellent results have been reported following anatomical reconstruction using a hamstring graft into the footprint of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) whilst maintaining the biomechanics of the ankle joint [2, 9]. Arthroscopy has been advocated as an adjunct to open ligament surgery in order to document and treat concomitant intra-articular pathology although several authors have recently published innovative techniques for arthroscopic repair [1, 3, 7, 8, 10, 11]. There have been only few papers describing arthroscopic reconstruction [5, 6]. This paper presents an entirely arthroscopic technique for gracilis graft (auto or allograft) reconstruction of the ATFL and the CFL. The procedure has been developed by the Ankle Instability Group following multiple cadaveric dissections by several

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Knee Surg Sports Traumatol Arthrosc

surgeons perfecting and simplifying the steps necessary for arthroscopic anatomical lateral ligament reconstruction.

an irrigation system. Arthroscopic dissection is performed using a 4.5 mm bone/soft tissue shaver blade. Summary of this surgery is as below.

Indications

1. Make the bone tunnels at fibular, talar and calcaneal attachments of the lateral ligaments. 2. Introduce the tendon graft to each bone tunnel, using a Toggle Lock® (Biomet,) or any other device of this type in the fibular bone tunnel. A bone suture anchor is placed in the talus, and an inside-out technique for the calcaneal bone tunnel. 3. Fixation of the tendon graft is with a Toggle Lock® in the fibular bone tunnel and interference screws in the talus (5 × 15 mm) and calcaneus (7 × 25 mm).

Surgery is indicated for patients with recurrent instability of the ankle secondary to injury to the lateral ligament complex after failure of non-operative management. Although popular, the Broström-Gould procedure may not be adequate in cases of failed previous repair, where the patient’s remaining tissue is insufficient or with generalised ligamentous laxity or excessive body mass index.

Clinical assessment

Patient positioning

It is important to obtain a detailed history of the patient’s complaints to help differentiate between instability due to recurrent ligament injury and functional instability, not related to increased ligament laxity. Physical examination must include an assessment for generalised ligamentous laxity and of overall lower extremity alignment (in particular hindfoot varus malalignment) which, if not addressed at the time of surgery, may result in a high likelihood of failure of surgical repair or reconstruction. The range of motion (passive and active) of the ankle and subtalar joints is also noted and gastrocnemius tightness is assessed. The anterior drawer test and hindfoot inversion tests are used to assess for lateral ligament laxity.

The patient is placed in the lateral decubitus position with the pelvis slightly rotated 30° posterior. For position 1 the hip is externally rotated and the knee is flexed for harvesting the gracilis tendon for the autograft. Position 2 is used for anterior arthroscopy with the knee extended and the hip externally rotated. Position 3 is utilised for lateral endoscopy with neutral rotation of the hip and the knee extended (Fig. 1).

Imaging Standard weight-bearing plain radiographs include standing anteroposterior (AP) view, lateral and mortise views and a comparative Saltzman view, which is helpful to assess hindfoot alignment. Magnetic resonance imaging (MRI) may be helpful in the presence of deep pain to assess for concomitant osteochondral lesions and/or tendon injuries.

Surgical technique Equipment The technique is carried out either with a standard 4- or 2.7-mm-diameter arthroscope, depending upon surgeon preference. The authors consider the 4 mm 30° angle gives a better view, and the laxity allows complete exploration of the joint. Irrigation is provided by gravity pressure with a hanging saline 3 l bag or 50–60 mmHg pressure using

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Graft harvesting After harvesting, the graft is folded to create a 1-cm-long doubled segment with two single strand limbs, one for the ATFL reconstruction and one for CFL. A whip-stitch is placed on the 1-cm doubled end (which will be placed into the fibular tunnel) attached to a fibular internal fixation device. Whip-stitches are also placed on the CFL end (approximately 5.5 cm in length) and the ATFL end (approximately 4 cm in length). A similar preparation is performed if using an allograft gracilis tendon. Landmarks: identification and marking of portals The patient is placed into position 2. Four portals can be created to perform the procedure. The anteromedial portal is the first portal (portal 1). The second portal is the accessory anterolateral portal (portal 2). This portal is not marked on the skin as it is made under trans-illumination guidance when the arthroscope is positioned in portal 1 and viewing the lateral gutter. The delay in developing an arthroscopic lateral ligament reconstruction was in part due to the difficulty in visualising the CFL because of its extra-articular position. The CFL merges with the lateral talocalcaneal ligament and the peroneal tendon sheath as these attach to the calcaneus. Therefore using a sinus tarsi portal (portal 3) [and if needed a peroneal tendonoscopy (portal 4)] the precise

Knee Surg Sports Traumatol Arthrosc

Portal 4 is the accessory portal made for tendoscopy. It is placed 1 cm proximal and 1 cm posterior to the tip/apex of the fibula. Step 1 The arthroscope is placed in portal 1. It is important to make the portal with the ankle positioned in dorsiflexion and just medial to the tibialis anterior tendon in order to achieve good vision of the lateral gutter including the fibular origin of the ATFL and the ATFL itself including its insertion onto the talus (Fig. 3). Transillumination is used to create portal 2, and a shaver is introduced through this portal to debride the lateral gutter exposing the ATFL and its fibular and talar footprints. Once the ATFL footprint has been debrided, the position for insertion of the fibular tunnel guide pin between the CFL and the ATFL is identified. Step 2

Fig. 1  Position of the patient for lateral hindfoot endoscopy

The arthroscope is now placed in portal 2. Portal 3 is created at the sinus tarsi in the previously marked position as described above. A shaver is then introduced through portal 3 to complete the preparation of the malleolar ligament insertion. A guide pin is then drilled across the fibula, exiting the fibula posteriorly and proximally, with care taken to protect the peroneal tendons. The pin is overdrilled using a 4.5-mm cannulated drill and then a 6-mm cannulated drill is used to make the tunnel to a depth of 1 cm (Fig. 4). With the arthroscope in portal 3, dissection is performed along the lateral articular surface of the talus at the level of the subtalar joint. The lateral cortex of the calcaneus is then visualised just below the joint. Debridement is performed along the lateral subtalar joint, in order to expose the calcaneal insertion of the CFL between the lateral border of the calcaneus and the peroneal tendons. This step must be performed with great care in order to properly identify the fibres of the CFL insertion. A guide

Fig. 2  Landmark of portal 3

location of the CFL may be identified and dissected. Portal 3 is made at the cross section of two lines. The first line follows the superior border of the peroneus brevis tendon. The second line follows the direction of the lateral malleolar tunnel. This axis of the malleolar tunnel is 10°, rotating anteriorly to the axis of the fibula (Fig. 2).

Fig. 3  Lateral gutter of the ankle with lack of ATFL and visualisation of the peroneal tendon

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Fig. 4  The lateral side of the talus and the malleolar tunnel

Knee Surg Sports Traumatol Arthrosc

Fig. 5  Fixation of the ATFL transplant

pin is then placed in the calcaneal CFL footprint and drilled through the calcaneus. The direction is distal, posterior and medial. The 4.5-mm cannulated drill crosses both cortices. Step 3 The arthroscope is now inserted into portal 3. Using a shaver placed in portal 2, the talar insertion of the ATFL is completely exposed. A guide pin is then placed at the ATFL talar footprint under direct visualisation and then drilled to a depth of 20 mm using a 6-mm cannulated drill. The direction of the tunnel is slightly proximal, centred towards the middle of the talus. A bone suture anchor is then placed in the tunnel through portal 2. It is used as pulley to introduce the tendon graft. Step 4 One of the bone anchor sutures exiting portal 3 is tied to the suture of the talar limb of the ATFL (Fig. 5). The fibular fixation device is then introduced through portal 3, advanced through the malleolus, and then hooked on the posterolateral cortex of the fibula. By pulling the free suture of the bone anchor, the talar graft is now pulled into the tunnel. The talar fixation is then completed with a 5 × 15 mm biointerference screw. The final tensioning of the ATFL limb is achieved by pulling on the loop of the fibular fixation device with the ankle in a neutral position. Step 5 The arthroscope is now placed in portal 2. A guide wire with a suture eye is used to pass the CFL limb of the graft

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Fig. 6  Final aspect

into the calcaneal tunnel and is tensioned by pulling on the suture medially with the hindfoot in a plantar neutral position. Final fixation is achieved with a 7 × 25 mm interference screw. Because calcaneal bone tends to be soft, this screw is oversized and a longer screw is used. (e.g., for a 6-mm tunnel, a 7 × 25 mm screw is used). It is important to use the arthroscope to ensure that the screw is completely buried to avoid impingement on the peroneal tendons (Fig. 6). Accessory step: the tendoscopy A significant number of patients with chronic lateral ligament insufficiency also have pathology of the peroneal tendons, including tendinopathy and partial longitudinal ruptures. Tendoscopy allows visualisation of the peroneal tendons and may be helpful.

Knee Surg Sports Traumatol Arthrosc

If tendoscopy is deemed necessary, then portal 4 is made for the arthroscope after step 2. When making this portal, it is important after the skin incision to release and expose the upper peroneal retinaculum with the trocar or a clip. The 4-mm arthroscope is then introduced—from the tip of the malleolus, looking downwards and forward, the two tendons are visualised. A septum is visible separating the two tendons into individual tunnels. At this point on the superior edge of the peroneus brevis are the entrance of sinus tarsi and medially the location of the CFL. Dissection of the fat in this area and the sinus tarsi in step 3 will enable a clear view of the anterior edge of the CFL and the subtalar joint as well as allowing identification of concomitant peroneal tendon pathology. The post-operative protocol includes an immobilization in a walker boot for 15 days. Active and passive dorsi- and plantar flexion range of motion are started at 15 days. Inversion and eversion exercises were started at 6 weeks after surgery and full athletic activity at 12 weeks after surgery.

Discussion We describe the arthroscopic technique for anatomical lateral ligament reconstruction using a gracilis autograft or allograft for chronic ankle instability. This procedure is indicated when there is insufficient local tissue for a Broström-Gould reconstruction such as in revision cases. Although it is technically demanding and requires significant soft tissue dissection and debridement, the steps have been developed to make this a reproducible procedure. There may be concern that three devices are used to secure the graft into the fibula, talus and os calcis making the procedure complicated and expensive. Further work is also needed to ensure that the correct tension is applied to the graft. However, the development of this technique by The Ankle Instability Group has shown that the arthroscopic version of a well-recognised open procedure is feasible and reproducible across a wide number of surgeons experienced with arthroscopic techniques. It is the purpose of

this presentation to document the technique with a view to a clinical study investigating the results of such surgery in a cohort of suitable patients with chronic ankle instability. Cases have been performed in patients with instability and will be reported upon in a prospective clinical study.

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