Chronic Ankle Instability

Jennifer C. Van, DPM

Temple University Hospital
Foot & Ankle Surgery
 Lecture Outline
Anatomy
Medial Ankle Ligaments

Lateral Ankle Ligaments

Grading System
Diagnostic Testing
Acute Injuries
Chronic Injuries
Non-surgical Treatment
Surgical Treatment
Ligament Reconstruction

Direct Repair

Article Reviews
Conclusion
 Who Cares?
~ 2 million patients per year present to
ER with Ankle Injuries
60% severe sprains
Inversion Sprains account for 90-95%
of all ankle sprains
> 65 of the time, ATFL injured
Untreated injuries can lead to serious
repercussions
Degenerative joint disease
Chronic ankle instability
 Medial Ankle Ligaments
Deltoid Ligaments
Superficial
Tibiocalcaneal
Deep
Ant. Tibiotalar
Tibionavicular
Interm. Tibiotalar
Post. Tibiotalar

Photo Credit: http://www.aafp.org/afp/980201ap/wexler.html

 Lateral Ankle Ligaments
Lateral Ligament Complex
Anterior Talofibular
Intracapsular
Straight arrow
Calcaneofibular
Extracapsular
Curved arrow
Posterior Talofibular
Intracapsular
Arrow head
2004 by Radiological Society of North America
Classifications
AMA Standard Nomenclature System
Used across specialties
ODonoghue Classification
Most commonly used
Mann & Coughlin Classification
Related to treatment
AMA Standard Nomenclature
Grade I: Microscopic Tear of Ligament
Mild swelling & tenderness
No joint instability, WB w minimal pain
Grade II: Incomplete Tear of Ligament
Moderate pain, swelling, & ecchymosis
Mild to Moderate joint instability, WB w pain
Grade III: Complete Tear of Ligament
Severe pain, swelling, & ecchymosis
Significant joint instability, unable to WB
 Diagnostic Testing

Photo Credit: http://www.tabers.com/tabersonline/ub/view/Tabers/143062/29/ANTERIOR_DRAWER_TEST

Photo Credit: http://www.tabers.com/tabersonline/ub/view/Tabers/143062/29/ANTERIOR_DRAWER_TEST

Talar Tilt Test Ant. Drawer Test

CFL injury if > 10 ATFL injury if > 2cm
or > 5 vs.
uninjured
Real World VH 56 y/o F
Real World VH 56 y/o F
Real World VH 56 y/o F
Acute Injuries
Estimated 10% of all ER visits
Mostly plantarflexion, inversion
mechanism
Treatment
Conservative vs. Surgical
Patient selection
Expectations
Acute Injury

Video Credit: http://www.youtube.com/watch?v=0GoT-T-RAjk

Chronic Injuries
Repeated assault on lateral ankle
ligaments
Chronic pain and edema around ankle
Feeling of instability on uneven surfaces
Predispose patients to significant
osteoarthritis
Nonsurgical Treatment
Functional Treatment
Braces
Lace up braces
Semi rigid ankle supports
Ankle Taping
Elastic bandages, Tubigrip
RICE protocol
Cast Immobilization
Physical Therapy
 Purpose: Summarize best available evidence in last decade for managing
ankle sprains in the community
Methods: MEDLINE database from January 2000 to December 2009
Results
Mild to Moderate Sprains

Functional treatment options more effective than immobilization

Lace up supports most effective
Severe Sprains
Short period of immobilization in BK cast or pneumatic brace resulted in
quicker recovery than compressive bandage alone
Prevention
Semi rigid orthoses and pneumatic braces provide beneficial ankle
support and present subsequent sprains during high risk sports
 Surgical Procedures
Ligament Reconstruction
Elmslie Procedure
Chrisman-Snook
Snook et al
Direct Anatomical Repair
Brostrm Procedure
Goud Modification Photo Credit: http://health.howstuffworks.com/medicine/surgeries-procedures/about-weight-loss-surgery-ga.htm

Karlsson Modification
 Chrisman-Snook Procedure
Elmslie, 1934
Reconstruct ATFL and CFL using fascia lata graft
Chrisman and Snook, 1969
Eliminate Talus drill holes
Transverse Drill Hole in Fibula
Peroneus Brevis Tendon
Snook et al, 1985
Calcaneal Drill Hole
Suture graft in front of lateral malleolus
Mild eversion while suturing graft
Eliminate outer heel wedge after cast removal
 Elmslie Procedure

Photo Credit: Elmslie RC: Recurrent subluxation of the ankle joint. Ann Surg 100: 364-367, 1934
 Modified Elmslie Procedure
Chrisman-Snook
Split Peroneus
Brevis Tendon
transversely
through fibula
horizontally
through calcaneal
groove

Photo Credit: Chrisman OD, Snook GA: Reconstruction of lateral ligament tears of the ankle. An experimental study and clinical evaluation of seven patients treated by a new modification of the Elmslie procedure. J Bone Joint Surg 51A: 904-912, 1969
 Chrisman-Snook Procedure
Reconstructed Anterior
Talofibular ligament
Reconstructed
Calcaneofibular ligament

Photo Credit: Snook GA, Chrisman OD, Wilson TC: Long-term results of the Chrisman-Snook operation for reconstruction of the lateral ligaments of the ankle. J Bone Joint Surg 67A: 1-7, 1985
 Brostrm Procedure
Brostrm, 1966
Reports direct repair of lateral ligaments
Ends difficult to find and often healed in elongated
fashion
Gould et al, 1980
Reinforcement of repair with extensor retinactulum
Thorough examination of peroneal tendons
Karlsson et al, 1988
Modification of original procedure
Divide, shorten, reinserting, and imbricating injured
lateral ligaments to fibula
 Gould Modification

Inferior extensor retinaculum

Incise from lateral

insertion
Translate over ATFL

region
Reinforces direct repair
Limits inversion
Examination of Peroneals
Photo Credit: Chang, Thomas. Mater Techniques in Podiatric Surgery. 481-490, 2005.
Video(s)
 Karlsson Modification

Roughen surface of bone between fibular

Ligaments divided 3-
insertion of ligaments and articular cartilage
5mm from fibular
insertion Drill Holes anterior and distal fibular border

Photo Credit: Karlsson J, Bergsten T, Lansinger O, et al: Reconstruction of the lateral ligaments of the ankle for chronic instability. J Bone Joint Surg 70A: 581-588, 1988
 Karlsson Modification

Ligaments reinserted into roughened surface

Imbrication of proximal stump of ligaments
Photo Credit: Karlsson J, Bergsten T, Lansinger O, et al: Reconstruction of the lateral ligaments of the ankle for chronic instability. J Bone Joint Surg 70A: 581-588, 1988
 Purpose: Prospective and random comparison of outcomes of
Chrisman-Snook and Modified-Brostrm procedures for
chronic lateral ankle instability in 40 patients
Snook et al. Modification vs. Karlsson Modification
Materials & Methods: 40 patients, 2 w bilateral procedures
Standardized Talar Tilt
Prior to sx: 14 (range, 0 to 25), contralateral uninjured ankle
7 (range, 0 to 15)
13 (range, 0 to 24) Modified Brostrm group
14 (range, 0 to 45) Chrisman-Snook group
Post operative course
Immobilization x 2 weeks, SL Cast x 4 weeks
Follow Up Avg. 29 months (range, 6 to 49)
Sefton Scores
Excellent, Good, Fair, Poor
 Results: 18 (19 ankles) patients available for physical exam, xrays
10 Modified Brostrm group
0 ant. drawer, 1 + talar tilt
Post op talar tilt 7
9 Chrisman-Snook group
1 + ant. Drawer, 0 talar tilt
Post Op Talar Tilt
Modified Brostrm group, 7 (range, 6 to 15)
Chrisman-Snook group, 5 (range, 0 to 15)
Modified Brostrm group reported better Sefton Scores
Complications greater in Chrisman-Snook group
5/20 post op wound complications vs. 0 in Modified Brostrm group
11/20 sural nerve sensory loss, with 8/11 permanent vs. 2 temporary parasthesia
6/20 report ankles feeling too tight vs. 2 in Modified Brostrm group
 Purpose: Report long term results of
Modified-Brostrm procedures with ATFL
Reconstruction and Advancement of Inferior
Extensor Retinaculum
Methods: 30 patients treated with MBP
without CFL Reconstruction
26 males, 4 females
Clinical, functional, and radiographic
assessments
 Results
Hamilton Scores
Excellent 12/30 (40%)
Good 16/30 (53.3%)
Fair 2/30 (6.7%)
Poor 0/30 (0%)
No statistically significant differences between mean range
of DF and PF of operative foot and contralateral foot
Talar Tilt
Mean talar tilt of operated foot 3.0 (range, 0.6-10.4) and contralateral side
2.5 (range, 0.2 to 10.4)
Mean anterior drawer of operated foot 6.9 (range, 5.0 to 10.2) and
contralateral side 6.1 (range, 4.6 to 9.9)
 Purpose: Establish whether surgery or
functional treatment provides better long term
results for acute ruptures of lateral ankle
ligaments
Methods: Physically active Finnish men
(mean age, 20.4 years) with acute Grade III
lateral ligament rupture randomly allocated to
surgical (n=25) or functional (n=26) treatment
 Surgical Treatment
Suture repair of injured
ligament(s) within first
week after injury
BK plaster cast x 6
weeks with full WB
Functional Treatment
Aircast brace x 3 weeks
Full WB allowed
 Follow Up: Clinical Examinations at 6 weeks, 3
months, 3-4 years, and end period at 2005
15/25 (60%) surgical group vs. 18/26 (69%) functional
group
Results
Performance Test Protocol and Scoring Scale for the
Evaluation of Ankle Injuires
83 11 in sx group vs. 75 13 in functional group
Reinjury: 1/15 in sx group vs. 7/18 in functional group
 Imaging Results
Anterior Drawer: no difference between groups
Talar Tilt: no difference between groups
MRI: Articular Cartilage Evaluation
Grade II Osteoarthritis, 4/15 surgical group vs. 0/18 functional group
Conclusions
Recovery of preinjury activity level does not different
between treatment groups
Lateral ligament reinjury occurred less frequently in surgical
group, however, surgery may increase risk of subsequent
osteoarthritis
 Purpose: Case study, Reconstruction of
Lateral Ligaments using Extensor Digitorum
Longus Tendon Graft of Fourth Toe
Methods: 24 patients
21 reconstruction of both ATFL and CFL
3 reconstruction of only ATFL
Minimum f/u 24 months (mean, 37 months with
range, 24 to 57 months)
 Operative Technique
Arthroscopy of ankle joint
Harvest 4th EDL tendon, cut 2cm proximal
to insertion and suture distal remnant to 3rd
EDL and EDB
2 bone tunnels in lateral malleolus
3 holes parallel to previous bone tunnels
 Tendon graft secured to calcaneus with suture anchor after passed through bone
tunnels in lateral malleolus
On talar side, graft pass through remaining ATFL near near its talar attachment
may use suture anchors
 Suture graft back on itself over lateral
malleolus, double thickness graft for
ATFL
Graft fixed into distal base of ATFL
ligament on talar side and with the suture
anchor in calcaneal side
Stable reconstruction obtained with
additional repair of lateral ligament
remnants, periosteal flap, and inferior
extensor retinaculum
 Results
Sefton Grading
18 excellent, 5 good, 1 fair
Karlsson Scales
48.0 4.2 pre op (range, 37 to 60), 92.2 3.8 post op (range, 85 to
100)
Talar Tilt
12.3 1.1 pre op (range, 8 to 17), 4.3 0.8 post op
(range, 3 to 6)
Anterior Drawer
6.7 1.2mm pre op (range, 5 to 9mm), 3.4 0.6mm post op
(range, 2 to 5mm)
 What does the future hold?
Arthroscopic Repairs
Biomet JuggerKnot?
Glenoid anchor
Mean cortical failure load 239N
Mean cancellous failure load 194N
Study Result: Failure load not dependent on
anchor location (cancellous or cortical bone),
but dependent on anchor type (cuff anchor or
glenoid anchor)
Conclusion
Treatment
Surgical vs. Functional?
Patient selection equally as important
as treatment type
Sedentary Lifestyle?
Realistic goals?
 References
Elmslie RC: Recurrent subluxation of the ankle joint. Ann Surg 100: 364-367, 1934.
Chrisman OD, Snook GA: Reconstruction of lateral ligament tears of the ankle. An experimental study and clinical
evaluation of seven patients treated by a new modification of the Elmslie procedure. J Bone Joint Surg 51A: 904-912,
1969.
Snook GA, Chrisman OD, Wilson TC: Long-term results of the Chrisman-Snook operation for reconstruction of the lateral
ligaments of the ankle. J Bone Joint Surg 67A: 1-7, 1985.
Karlsson J, Bergsten T, Lansinger O, et al: Reconstruction of the lateral ligaments of the ankle for chronic instability. J
Bone Joint Surg 70A: 581-588, 1988.
Brostrom L: Sprained ankles. Vl. Surgical treatment of "chronic" ligament ruptures. Acta Chir Scand 132: 551-565, 1966
Chang, Thomas. Mater Techniques in Podiatric Surgery. 481-490, 2005.
Hennrikus, William, et al. Outcomes of the Chrisman-Snook and Modified-Bromstrom Procedures for Chronic lateral Ankle
Instability. American Journal of Sports Medicine. 24, 400-404, 1996.
Pihlajamaki, Harri, et al. Surgical Versus Functional Treatment for Acute Ruptures of the Lateral Ligament Complex of the
Ankle in Young Men. J Bone Joint Surg 92A:2367-74, 2010.
Lee, KT et al. Long Term Results after Modified Brostrom Procedure Without Calcaneofibular Ligament Reconstruction.
Foot and Ankle International 32. 153-157. 2011.
Barbar FA, et al. Biomechanical Analysis of Pullout Strengths of Rotator Cuff and Glenoid Anchors: 2011 Update.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 7 (July), 2011: pp 895-905.
Thank You!