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Early results of arthroscopic lateral ankle ligament reconstruction promising
Anterior drawer tests were negative in most patients after lateral ankle ligament reconstruction with an arthroscopic Brostrom Gould-type technique.
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All ankle instability symptoms improved in an initial series of patients who underwent a new arthroscopically assisted lateral ankle ligament reconstruction, according to the surgeon who developed the technique.
To reinforce the original repair, however, five of eight patients needed another suture subsequently passed through the fibular periosteum and into the inferior extensor retinaculum, according to Peter G. Mangone, MD, of Blue Ridge Bone & Joint Clinic, Asheville, N.C.
“Postoperatively they do well. They return to functional activity,” he said at the 2010 Summer Meeting of the American Orthopaedic Foot and Ankle Society.
At the meeting, Mangone discussed results with the first eight cases he performed from November 2007 to December 2009, all of which were done in patients with “profound instability” and who would not need to return to high-level activities.
Uses two anchors now
Mangone said when he started performing the procedure he placed just one bioabsorbable bone anchor, which worked well. But in keeping with the trend in shoulder surgery of better results with more rather than fewer anchors, he has switched to using two of them. He said results are now even better with the technique, which is indicated for patients suited for an open Brostrom procedure.
“We are on the dawn of a new era. I think this needs to be looked into further with a prospective study compared to open Brostrom, biomechanics, and potentially with an all-inside technique,” Mangone said.
He and a colleague have successfully completed 12 additional cases using the new method he described, but results were too short-term to present.
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Images: Mangone PG |
Technique description
The first patients treated with the minimally invasive procedure had positive anterior drawer and tilt tests and failed nonoperative measurements. In the operating room Mangone fitted them with an ankle distractor and examined them under anesthesia. Using the two usual arthroscopic portals, he cleaned out the lateral ankle gutter a bit more than usual to better visualize the lateral area.
“A 30° scope is enough to do that,” Mangone said.
Through the anterior lateral portal, Mangone placed one or two resorbable bone anchors in the distal anterior inferior fibula with the suture also exiting in that area. “The second anchor is placed slightly dorsal to that or cephalad,” he noted, explaining the suture for the first anchor passes through the inferior extensor retinaculum and the capsule. The other goes through the anterior talofibular ligament area of the capsule on the anterior extensor retinaculum.
To pass sutures through the ligament complex, Mangone recommended using a sharp-tipped suture passer or microsuture device with an outside-in or inside-out technique. Finally, he removes the distractor and places the ankle in slight dorsiflexion to tie down the lateral ligament.
Initially patients wear a cast, and later switch to a brace. Mangone reported no major wound or nerve complications and negative post-surgical drawer tests in seven patients. – by Susan M. Rapp
Reference:
- Mangone PG. Arthroscopically assisted lateral ligament reconstruction. Presented at the 2010 Summer Meeting of the American Orthopaedic Foot and Ankle Society. July 8-10. National Harbor, Md.
- Peter G. Mangone, MD, can be reached at 60 Livingston St., Suite 100, Asheville, NC 28801; 828-258-8800; e-mail: pmangone@brbj.com. He is a paid consultant to Arthrex.
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