Lateral Ankle Ligament Reconstruction Using Plantaris Autograft

Indications

Symptomatic chronic lateral ankle instability with insufficient local tissue (ligament remnants, extensor retinaculum)
Failed primary lateral ankle ligament repair

Indications Pitfalls

Heel varus, tibial varus misalignment, and muscular disbalance (e.g., peroneus brevis incompetence, posterior tibial contracture) must be addressed at the time of surgery.

Indications Controversies

Stress radiographs do not correlate with symptomatic lateral ankle instability ( ).
A medial ankle instability may result in symptomatic rotational instability ( ).
A peritalar instability with valgus tilt of talus may hide a lateral ankle instability ( ).

Diagnosis and treatment are based on typical history and clinical findings.
Patients complain of insecurity, instability, and giving way on uneven ground with difficulties in sports and/or daily activities.
While the patient is sitting and the lower leg is hanging free, the stability of the ankle can be tested in all planes ( Figs. 65.1 and 65.2 ).
In addition, functional ankle instability can be diagnosed with gait analysis or prolonged peroneal muscle reaction time on electromyography ( ).
The finding of laxity may be documented by stress inversion or anterior drawer films.
- A talar tilt of more than 5° difference from the contralateral uninjured ankle is usually considered pathologic ( ).
- Anterior subluxation of over 6 mm is usually considered pathologic ( ).

Treatment Options

Acute lateral ankle sprains should be managed in general first by functional rehabilitation ( ).
Anatomic ligament repair is indicated after failed nonoperative treatment ( ).
In cases of insufficient ligament remnants, augmentation with autogenous tendon, allograft, or internal braces should be considered.

Anterior tibiofibular ligament (ATFL)
- It blends with the anterior capsule of the ankle.
- It originates at the talar neck 18 mm above the subtalar joint and runs to the anterior edge of the fibula, just lateral to the articular cartilage.
- Its center of attachment is 10 mm proximal to the tip of the fibula ( Fig. 65.3A ; ).
- It is the first ligament that restricts the foot against supination.
Calcaneofibular ligament (CFL)
- It originates 13 mm distal to the subtalar joint and crosses the subtalar joint in a perpendicular way when the foot is in neutral position.
- Its center of attachment is on the anterior surface of fibula 8.5 mm above the distal tip just below the origin of the ATFL ( Fig. 65.3B ; ).
- It restricts the subtalar and ankle joints against inversion and internal rotation of the subtalar joint.
A significant part of fibers of the CFL blend into the fibers of the ATFL.

The patient is placed supine with a wedge under the ipsilateral hip.
Draping includes the calf for optional plantaris tendon grafting ( Fig. 65.4 ).
The leg is exsanguinated with an Esmarch bandage, and a thigh tourniquet is inflated.
After arthroscopy is completed, the table may be tilted to the contralateral side to facilitate the lateral approach.

Positioning Equipment

We do not use a distraction device during ankle arthroscopy.
This facilitates functional assessment of ligament competence and recognition of the instability pattern.
We prefer the use of carbon dioxide–medium for arthroscopy to avoid swelling of surrounding soft tissues.

Positioning Controversies

The use of an ankle traction device may facilitate insight to the joint during arthroscopy, but also hide the instability pattern.

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

If you are a member. Log in here