SLR - August 2023 - Blake Wallace, DPM
Title: Revision lateral ankle ligament reconstruction for patients with a failed modified Brostrom procedureReference: Xu Y, Cao YX, Li XC, Xu XY. Revision lateral ankle ligament reconstruction for patients with a failed modified Brostrom procedure. J Orthop Surg (Hong Kong). 2022 Sep-Dec;30(3):10225536221125948. doi: 10.1177/10225536221125948. PMID: 36113017.
Reviewed By: Blake Wallace, DPM
Residency Program: Ascension St Vincent, IN
Podiatric Relevance: Lateral ankle instability (LAI) is a common pathology seen in the foot and ankle. The most common surgical approach to address LAI is the modified Brostrom procedure. This technique yields good results and has been backed by research over the years. However, a small subset of patients develop recurrence postoperatively. In this patient population, the foot and ankle surgeon must choose a surgical technique that reinforces the repair of the lateral ankle ligaments in a more robust manner than the modified Brostrom. This paper demonstrates a revision technique involving the use of semitendinosus allograft and Tightrope system in a percutaneous approach.
Methods: This was a retrospective review of 21 patients treated between March 2017 and April 2020 by one surgeon. Inclusion criteria were 1) previous failed modified Brostrom procedure, and 2) persistent symptoms like pain, and 3) minimum 6 months from failed surgery to revision surgery. Exclusion criteria were 1) ankle fracture, 2) other ankle surgeries, 3) osteochondral lesions or synovitis on preoperative MRI, 4) obvious ankle arthritis, and 5) ankle instability with cavovarus deformity. The technique involved percutaneous drilling through the fibula in a distal anterior to proximal posterior fashion, inserting the middle of a semitendinosus allograft into the anterior fibula hole, and securing it with Tightrope through the posterior hole. Then, biotenodesis fixation was utilized on the two ends of the allograft into the calcaneus and talus for reconstruction of ATFL and CFL.
Results: The average time from the first surgery to revision operation was 29 months (6-120), and the mean follow up was 39.2 months (24-61). The VAS score improved from 4.1 ± 1.5 preoperatively to 1.3 ± 1.3 at final follow up (p < 0.05). The Karlsson-Peterson (KP) ankle scoring system improved from 59.0 ± 20.2 preoperatively to 88.2 ± 9.6 at the final follow-up (p < 0.05). The mean varus tilt angle was 14.1 ± 3.9 mm preoperatively vs 4.9 ± 4.7 at the final follow up (p < 0.05). The mean anterior talar displacement was 12.8 ± 2.2 mm vs 5.6 ± 3.7 mm at the last follow-up (p < 0.05).
Conclusions: Lateral ankle ligament reconstruction following a failed modified Brostrom procedure has had many surgical treatment modalities explored over the years. Many of these options include sacrificing native tendons and non-anatomic repairs. The surgical approach described in this paper demonstrates an effective method to reconstruct lateral ankle ligaments using minimally invasive incisions, semitendinosus allograft, and Tightrope. More studies should be undertaken comparing results of other revision surgery to this technique in order to demonstrate effectiveness in various approaches. Additional research could also include larger patient population, single blinded studies, and randomization. Regardless, the technique described in this paper can serve as an effective alternative to other revision surgeries, demonstrating favorable results.