Ligament Reconstruction for Chronic Medial Ankle Instability

Chronic medial ankle instability based on patient’s feeling of “giving-way,” especially toward medial, when walking on even ground, downhill, or downstairs

Pain at the anteromedial aspect of the ankle, and sometimes pain in the lateral ankle, especially during dorsiflexion of the foot

Progressive pronation deformity

Secondary tendinosis of posterior tibial (PT) tendon

Standing test (anterior view): pronation deformity of the affected foot (excessive valgus of the hindfoot and pronation of the foot; Fig. 70.1A ) disappears when the PT muscle is activated ( Fig. 70.1B ).

Standing test (posterior view): pronation deformity of the affected foot (excessive valgus of the hindfoot and pronation of the foot; Fig. 70.2A ) disappears when the PT muscle is activated ( Fig. 70.2B ).

Medial ankle pain

• Pain in the medial gutter, as typically provoked by palpation of the anterior border of medial malleolus

• The result of underlying synovitis due to chronic shifting of the talus within the ankle mortise

Anterior drawer test

• Increased when the foot is externally rotated (as compared with internal rotation)

• Highly sensitive test for medial ankle instability

Plain weight-bearing radiographs, including anteroposterior views of the foot and ankle and lateral view of the foot, should be obtained to rule out

• Old bony avulsion fractures

• Secondary deformity of the foot (e.g., valgus malalignment of the heel, and dislocation at the talonavicular joint)

• Tibiotalar malalignment (e.g., medial gapping of the joint due to incompetence of the deltoid ligament)

Stress radiographs may be helpful to discern an incompetence of the deltoid ligament in treatment of acute ankle fractures ( ), but they are not helpful in chronic conditions ( ).

Computed tomography scans may be initiated to detect a talocalcaneal coalition, or bony fragmentation that involves the articular surfaces.

Magnetic resonance imaging may reveal an injury to the deltoid ligament, particularly in acute conditions, and may also show pathologic conditions of the PT tendon.

Ankle arthroscopy is used to evaluate the stability of the ankle and discern associated intraarticular lesions (e.g., to the cartilage).

The deltoid ligament is a multiband complex with superficial and deep components ( Fig. 70.3A ; ; Harper, 1987 ; ).

It may be wise to differentiate the superficial and deep portions of the deltoid complex with respect to the joints they are spanning.

• The superficial ligaments cross two joints: the ankle and the subtalar joints.

• The deep ligaments cross only one joint, the ankle joint, although differentiation is not always absolutely clear.

The three superficial and more anterior bands ( Fig. 70.3B ) are the tibionavicular ligament (TNL), tibiospring ligament (TSL), and tibiocalcaneal ligament (TCL). There are three deep bands constituting the anterior, intermediate, and posterior tibiotalar ligaments (TTL).

As the tibioligamentous portion of the superficial deltoid has a broad insertion on the spring ligament (Spring L; Fig. 70.3B ), this ligament complex may interplay with the deltoid ligament in the stabilization of the medial ankle joint, and thus functionally not be separated from it.