Which Nerves Can Be Damaged During Ankle Ligament Repair Surgery

Injury to the lateral ligaments account for 15% to 25% of all muskuloskeletal injuries and as many every bit 50% of injuries in sports that require cutting and jumping. ^1,42,50 Most low-grade injuries probably never are evaluated by a physician and either treated in the training room or non at all. Patients with higher-form injuries usually have significant hurting and swelling and are more than probable to seek medical care acutely or shortly after the injury. Twenty to forty% of patients with severe sprains will have continued issues with hurting and instability. ^{ane,3,v,9,ten,xviii,21,24,25,38,39,47}

Controversy continues to develop over the best handling for Course 3 ankle sprains with consummate disruption of the lateral ankle ligaments. Comparative studies of functional handling versus acute surgical repair of the ruptured ligaments have been done with some advocating improve results with surgical repair, and others finding no departure in final issue betwixt surgical and functional treatment. ^{two,10,22,24,29,43,51,53,57,58,65}

More than 50 surgical procedures take been described for the treatment of chronic lateral ankle instability, ^7,eight,56 almost of which focus on the reconstruction of mechanical restraints to talar instability. Anatomic reconstruction attempts to either direct repair the injured ligaments or supercede them with local or transferred tissue. Anatomic reconstruction of the injured ligaments restores normal resistance to anterior translation and inversion without brake of subtalar or talocrural joint move. ^three,xviii Straight repair of the ligaments as described past Brostrom ¹¹ is not always possible because attenuation of the tissue may occur with chronic repetitive trauma. Other techniques take been adult to achieve more than reproducible stability by either directly advancing the ligaments into bony troughs in the fibula, ^{31,37,38,48,71,74} augmenting the repair with local tissues, ^28,thirty,71 or anatomic tenodesis procedures that completely replace the ligaments with local grafts from the peroneus brevis, peroneus longus, accessory peroneal, peroneus tertius, fibular periosteum or afar grafts from the plantaris, palmaris longus or fascia lata. ^{3,four,12,17,18,xx,40,54,63,64,66–68,74}

Nonanatomic reconstructions also have been used extensively in the handling of lateral ankle instability and function to control talar instability by applying restraint to inversion and anterior translation. These procedures do not attempt to restore local beefcake, but create restraints to abnormal motion by positioning graft material perpendicular to the perceived instability. The nigh frequently reported nonanatomic reconstructions are modifications of those described by Watson-Jones, ⁷⁷ Chrisman and Snook, ^fourteen and Evans. ²¹ These tenodesis procedures have been shown to dramatically alter the biomechanics of the talocrural joint and subtalar joints, and significantly alter the normal plantar loading of the hindfoot, midfoot, and forefoot. ^{3,half-dozen–eight,18,41,61,63} Functional instability of the ankle results from disruption of normal arthrokinetic reflexes attributable to injured ankle ligaments and loss of proprioception. ^15,24,26,61 Surgical treatment of lateral ankle instability through ligament reconstruction, tenodesis, or muscle transfer improves proprioception and improves functional stability in a higher place the mechanical constraints of the reconstruction. ^{half-dozen,25,30,34,44,52,75}

Success of surgery in selected individuals is reported to be high with several studies reporting expert and excellent results between 80% and 95% regardless of the type of surgical procedure. ^16,56 Surgical complications are exceptional but present issues when encountered. The summary data presented in Tabular array ane, include only studies in which complications were reported. Studies in which the authors did not comment on the presence or absence of surgical complications were excluded from this tabular array and at that place may have been significant variation on what was considered noteworthy; therefore, the reader is cautioned to interpret the summary numbers cautiously. Complications of surgery can occur early in the postoperative menses and are straight related to surgical technique, patient compliance, and postoperative protocol. Early complications usually are related to wound healing, infection, or injury to the cutaneous fretfulness of the talocrural joint. Recurrent instability can be a hard problem to address and tin can result from reinjury, but is more commonly associated with selection of a process that does not adequately recreate the mechanical restraints required for stability. Patients with unusual weather condition such as ligamentous laxity and cavovarus human foot deformity are at high chance for having recurrence if these underlying atmospheric condition are not addressed at the primary process. A common reason for residue disability, particularly with tenodesis procedures, is loss of movement of the talocrural joint and subtalar joints. Long-term complications of degenerative joint disease of the talocrural joint and subtalar joint are well-recognized, although it is unclear whether these are sequelae of repetitive trauma from preoperative instability or attibutable to aberrant joint loading after reconstruction. The purpose of the current study is to review reported surgical complications and to suggest treatment options when these complications are encountered.

TABLE i:

Summary of Complications

Wound and Nerve Complications

Wound complications after lateral ankle ligament reconstruction are common. In reviewing serial of surgical treatment of ankle instability, at that place were 41 reports of superficial or meaning wound healing bug in 1516 cases (Table i). About all wound complications were superficial and responded to local wound care. Hennrikus et al ³¹ reported higher wound complexity rates with the Chrisman-Snook procedure than the Brostrom process including ii patients with wound dehiscence. The use of carbon fiber to reconstruct the ligaments of the ankle was associated with significant wound healing problems and infection. Freedman et al ²³ reported five infections with carbon fiber reconstruction of the anterior talofibular ligament and posterior talofibular ligament. The strange material was removed in all infected cases and a revision was done in three cases. Septic arthritis ³³ and calcaneal osteomyelits ⁵⁹ have been reported, but deep infections are rare. Patients with these complications crave surgical debridement and thorough irrigation to remove infected hematoma and necrotic tissue. Culture-specific antibiotics are of import to eradicate the infectious process. Attempts should be made to retain the ligamentous construct, simply if foreign material or allograft were used, staged reconstruction after radical debridement may be indicated.

Nerve dysfunction after ankle ligament reconstruction has been reported to be as high as 52%^6,32 and may range in severity from a subjective feeling of hyposensibility to astringent disabling pain from neuroma or entrapment. ⁷⁰ In reviewing reports of surgery for acute or chronic lateral talocrural joint injury, an overall incidence of 6.2% (94 of 1516) of reported nerve complications including sensory deficits of the dorsal lateral foot and toes and painful neuromas requiring surgical exploration or excision are seen (Table ane). The sural nerve seems to exist at greater risk with peroneal tenodesis procedures, and the superficial peroneal nerve is at greater risk with acute or delayed repair of the ligaments. Other reported perioperative complications include reflex sympathetic dystrophy and other neurogenic pain syndromes, deep venous thrombosis, and pulmonary embolus. ^{iv,22,43,46,66,67,71}

Recurrent Instability

Recurrent instability after talocrural joint reconstruction is reported with every blazon of repair including acute and delayed chief repairs and in anatomic and nonanatomic tenodesis procedures. Failure of the reconstruction to right instability may exist classified into four groups. The process may fail because of inadequate reconstruction of the anatomic constraints, the patient may proceed to have functional instability despite solid ankle ligament reconstruction, reinjury to the ankle tin can occur, or a predisposing factor that was overlooked during the initial surgery may be present.

Nonanatomic Tenodesis Procedures

The failure of initial surgery to establish mechanical stability is dependent on the type of process selected, the plane of mechanical instability beingness addressed, and the ability of the surgeon to technically constitute the goals of the procedure. In addressing postoperative instability after nonanatomic tenodesis procedures such as the Watson-Jones, Evans, and Chrisman-Snook procedures, it is helpful to consider anatomic and biomechanical information, because restoration of normal mechanical restraints is non achieved with these procedures. ^{three,xviii,62}

Subjective instability after the Watson-Jones tenodesis has been reported to be from 3% to 66%. ^{four,vi,12,13,27,32,49,76} This wide range probably results from different evaluation parameters, but some authors retrieve that the procedure is able to achieve practiced long-term stability. ^27,49 Others have reported continued instability in talar tilt testing. ¹⁸ Radiographic instability, however, does non always correlate with a poor functional outcome. ^xiii,33 In a review of nine patients with an average 22-year followup, Van der Rijt and Evans ⁷⁶ noted a high rate of subjective instability, and deterioration of talar tilt and anterior drawer stability with time.

Serial sectioning of the inductive talofibular ligament and calcaneofibular ligament was done by Bahr et al ^three and the patterns of instability were compared with the Watson-Jones tenodesis. The Watson-Jones reconstruction restored stability in all planes at the tibiotalar joint just did not restore stability to the subtalar joint. The posterior limb of the graft in the Watson-Jones reconstruction was under significantly greater strain during loaded supination testing and joint motion was restricted compared with the normal talocrural joint in plantar flexion, supination, and internal rotation. This may explain why the subjective and objective stability of this procedure deteriorate with time. ^13,76 In a cadaver model, Colville et al ^xviii found that Watson-Jones reconstruction controlled anterior drawer testing and internal rotation, but that talar tilt was not controlled and subtalar move was diminished. Other studies confirmed the inability of the Watson-Jones procedure to restore normal joint kinematics. ^41,62

The Evans tenodesis procedure has been used extensively for correction of lateral ankle instability. Subjective instability subsequently this technique is ix% to 83%. ^{5,seven,13,32,36,55,lx,74} In a cadaver model, Colville et al ¹⁸ reported the procedure failed to correct abnormal displacement of the talus with inductive drawer testing and talar tilt testing, and failed to correct internal rotation when compared with ankles with intact ligaments. Rosenbaum et al ⁶² reported marked diminution of subtalar motion and showed that ankle stability with this procedure is accomplished past reducing subtalar move to a nonphysiologic level. In clinical studies, several authors observed objective instability and fair or poor results correlated highly with continued clinical instability. ^36,55 Others constitute no correlation betwixt objective instability and functional results. ^5,viii,13 In studies with an average followup less than 10 years, the average good or excellent clinical results was 92%, ^7,8,32 but iii studies reviewed with greater than x years followup averaged only 71% good or splendid results, ^5,36,55 suggesting that results deteriorate with time.

The Chrisman-Snook procedure has undergone many modifications, and has a high rate of reported patient satisfaction. Of the nonanatomic tenodesis procedures, the Chrisman-Snook procedure had the lowest percentage of postoperative subjective instability, ranging from 0% to eighteen%. ^{xiii,xiv,31,32,72–74} The procedure achieves meliorate stability in talar tilt considering of a straight reconstruction of the calcaneofibular ligament by attaching it'due south posterior limb to the calcaneus. ^xiv In a cadaver model, Colville et al ^eighteen showed it to be effective in limiting talar tilt, but allowed continued anterior translation and internal rotation. Modifications to the anterior limb align the graft anatomically to address this problem. ⁷³

Anatomic Tenodesis Procedures

Anatomic reconstruction of the lateral ligaments using either a tenodesis or complimentary tendon graft essentially is a modification of the original procedure described by Elmslie. ²⁰ These procedures endeavor to approximate the anatomic origins and insertions of the anterior talofibular ligament and calcaneofibular ligament. The correct insertion point is identified past dissecting and identifying the torn or adulterate ligament and tracing it to its zipper indicate on the calcaneus or talus. Anatomic reconstruction controls rotational stability, talar tilt and inductive subluxation, while preserving normal joint kinematics. ^iii,18,62 Clinical studies of anatomic tenodesis procedures that noted low subjective instability (0% to 3%) had clinically good or excellent outcomes in 91% to 100% of patients. ^54,67,68

Delayed Master Repair of Ligaments

Brostrom ¹¹ get-go described direct repair of chronically torn ankle ligaments in patients with instability. Bahr et al ³ showed that repair of the anterior talofibular ligament and calcaneofibular ligament restored normal ankle motion and control of talar tilt, although inductive translation was not controlled too as with tenodesis procedures. Attenuation of the anterior talofibular ligament and calcaneofibular ligament may occur, peculiarly in patients with long-continuing instability, ³⁷ but local augmentation with retinacular or periosteal flaps has yielded long-term results that are like to other, more than extensive tenodesis or reconstructive procedures. ^{28,30,38,64,71} Subjective residual instability take been reported to be 5% to 12%, ^31,37,38,47 and good or excellent results accept been reported to be 75% to 96%. ^{thirty,31,37,38,47}

Traumatic Recurrence of Instability

In the reviewed serial, no acute or delayed procedure can be described as existence more than protective or at risk for recurrent sprains. Afterwards acute repair, Agoropoulos et al ² described two recurrent severe sprains in athletes who were treated conservatively and did non require additional surgery. Povacz et al ⁵⁸ also reported that after 73 acute ligament repairs, xx patients had additional ankle sprains in the 2-year followup catamenia, although none required boosted surgical treatment. A severe sprain after delayed ligament reconstruction was reported by Hennrikus et al. ³¹ The patient did non respond well to conservative treatment and afterwards was treated with the Chrisman-Snook procedure.

Significant ankle trauma can cause failure of previously successful tenodesis procedures. In two of the 3 patients with unsuccessful results after undergoing the Evans procedure, Barnum et al ⁵ observed that successful initial treatment had been complicated by reinjury of the ankle causing functional instability. Larsen ⁴⁵ observed rupture of an Evans tenodesis later on a patient sustained a fall of ii m. Snook et al ⁷³ reported three severe sprains after Chrisman-Snook procedures that acquired disruption of the tenodesis and recurrence of instability. Two patients were treated with bandage immobilization and had return of significant talocrural joint instability that did non respond to therapy. The patients were offered revision reconstruction but declined. The third example was complex. The patient had ligamentous laxity and had multiple reconstructions of the medial and lateral ankle ligaments. She did poorly after revision surgery. In a series reported past Brunner and Gaechter, ¹² rupture of the graft occurred in 2 patients after Watson-Jones tenodesis, and the patients required revision fixation. Sammarco and DiRaimondo ⁶⁷ and Sammarco and Carrasquillo ⁶⁶ described four cases where the tendon graft was ruptured with significant trauma. The graft in one patient who jumped from a five ft platform onto a curb healed uneventfully with bourgeois treatment. ⁶⁶ One patient who stepped into a pigsty, ⁶⁷ and two with high impact sports injuries ⁶⁷ were treated with revision anatomic reconstructions. These patients had subsequent successful outcomes.

Predisposing Factors

Ligamentous laxity has been reported past several authors to be associated with recurrent instability after ankle ligament reconstruction. In 2 large series, Karlsson et al ^35,38 reported that direct repair of the ligaments in patients with generalized joint hypermobility presents a meaning hazard for mechanical failure of the procedure. Connective tissue disease such equally Ehlers-Danlos or Marfan's syndrome may make autogenous tissue unsuitable. Schon did successful ankle ligament reconstruction using hamstring allograft and bone anchors in a patient with Ehlers-Danlos syndrome after a failed Chrisman-Snook process (Personal oral communication, Lew C. Schon, MD, 1999), whereas other authors have suggested the use of carbon fiber material in such cases. ^7,23 Colville ¹⁶ suggests that the master procedure should limit subtalar motility if generalized ligamentous laxity is nowadays.

Cavovarus deformity of the foot likewise has been reported to be a predisposing factor to the development of ankle instability. ⁴⁶ With the heel in varus, the weightbearing centrality is medialized in relation to the ankle, placing higher demands on the lateral ligament circuitous. Sammarco and Taylor ⁶⁹ observed lateral ankle instability as a presenting complaint in 24% of patients reviewed for surgical correction of cavovarus foot deformity. Correction of the underlying deformity through calcaneal and metatarsal osteotomies resolved the instability in these patients and ligament reconstruction was not necessary. Brunner and Gaechter ¹² reported varus deformity of the calcaneus every bit a reason for recurrence of instability after Watson-Jones tenodesis. Brostrom ¹⁰ reported failure of lateral ligament repair in a patient with Charcot-Marie-Tooth illness who had cavovarus foot deformity and peroneal weakness.

Treatment of Recurrent Instability

Evaluation of the patient who presents with poor results afterwards ankle ligament reconstruction requires a thorough history and an indepth knowledge of the primary procedure that was done. Conservative treatment of recurrent instability is identical to that for the preoperative state and should be tried in all patients. Failing conservative treatment, the source of continued instability must exist evaluated carefully earlier proceeding with additional surgery. Clinical and radiographic stress testing should exist repeated to evaluate instability. Continued episodes of giving way can exist caused by other nonligamentous disorders and should be investigated. Many authors have reported a high incidence of concurrent intraarticular lesions and peroneal tendon disorders with chronic instability, ^{19,27,33,42,54,67,68,73} and this may continue to give symptoms if not addressed at the initial surgery. Magnetic resonance imaging of the ankle can be helpful in defining concomitant osteochondral fractures, loose bodies, and tendon disorders, just imaging of the reconstructed ligaments is difficult to interpret considering of scarring and contradistinct anatomy later surgery.

Surgical planning should include a review of the previous surgeons' operative report, focusing on the blazon of procedure that was done and what tissues may have been used during the initial procedure. If the primary procedure was a direct ligament repair, it may exist possible to exercise revision to a standard tenodesis procedure.

Approaching failed previous tenodesis procedures is more than complex. Preoperative stress films will help determine which limb of the reconstruction is insufficient. Repositioning of graft material is preferable to consummate removal of the previous grafts, and it ofttimes is possible to spare i of the limbs of the reconstruction if only one plane of instability is present. For example, if a patient previously has undergone Watson-Jones reconstruction, and preoperative stress films reveal increased talar tilt but stable anterior drawer testing, information technology is reasonable to harvest the posterior limb of the graft and use this limb to reconstruct the calcaneofibular ligament by attaching information technology to the calcaneus. Sammarco and Carrasquillo ⁶⁶ described repositioning of the previous graft textile without harvest of a new graft if the original placement was nonanatomic, and the remaining material was acceptable. Snook et al ⁷³ reported that one of the limbs had dissolved completely in a revision tenodesis process. In this case, the surgeon must be prepared to harvest a new local or afar graft for reconstruction. In the only series of revision talocrural joint ligament reconstruction surgeries, Sammarco and Carrasquillo ⁶⁶ reported a 90% success rate using anatomic tenodesis.

In patients who accept not responded to reconstruction because of underlying cavovarus deformity, it is of import to accost the underlying mechanical issues with the hindfoot and forefoot. Simple revision of the ligament reconstruction is doomed to failure because the underlying varus moment will keep to stress and stretch out the ligamentous reconstruction. Considering of the marked increase in the magnitude of surgery required for correction of cavovarus deformity, it is wise to talk over the utilize of more extensive braces before surgical reconstruction. An talocrural joint foot orthosis unremarkably volition control the instability, although immature active patients will be less likely to take its limitations. Neurologic workup may exist appropriate if the deformity has been worsening, or if motor imbalance is nowadays. In patients with isolated hindfoot varus, a concomitant lateral closing wedge osteotomy can be done simultaneously to right the heel to approximately v° valgus. This will protect the reconstruction and normalize the weightbearing centrality. If midfoot cavus too is nowadays, the calcaneal osteotomy should incorporate a lateral shift or lateral closing wedge and a proximal shift to decrease the calcaneal pitch bending. If significant forefoot varus is present, the surgeon too may need to exercise metatarsal osteotomies and plantar soft tissue release to create a plantigrade foot. ⁶⁹ In the presence of subtalar arthritis and hindfoot varus, subtalar arthrodesis with realignment of the hindfoot in slight valgus should accompany revision of the talocrural joint ligaments.

Postoperative Stiffness

Postoperative talocrural joint and subtalar stiffness is a commonly reported complexity afterwards anatomic and nonanatomic reconstructions. The development of a strong hindfoot results from i cistron or a combination of factors. Graft positioning is extremely important in achieving normal joint motion after surgery. Some nonanatomic ligament reconstructions attain their results by directly limiting subtalar motion; therefore, postoperative stiffness really is a desired outcome. In anatomic reconstructions, malpositioning of the graft limbs may crusade an undesired reduction of subtalar or ankle motion.

Gauging the tension of the reconstruction maybe is the virtually hard part of the process. To date, no studies have been washed to quantify appropriate graft tension with different tenodesis procedures. The hindfoot should be held in eversion while tightening the graft, simply information technology is important to ensure that the graft is non tensioned with the subtalar joint in forced eversion. Overtightening of the graft is a technical mistake that can lead to symptomatic stiffness and continued hurting. ^{viii,12,sixteen}

Colville and Grondel ¹⁷ observed symptomatic stiffness in ii patients who had extended bandage immobilization after surgery. Early on motion after surgery is important in avoiding debilitating stiffness, and with modern fixation techniques, it is possible to accomplish adequate stability and so that cast immobilization tin exist discontinued at iii to 4 weeks. The patient is immune to bear weight wearing a boot walker and is started in physical therapy with active and gentle passive motility of the ankle and subtalar joints. Depending on the type of procedure that was done and the degree of stability accomplished intraoperatively, more aggressive strengthening and motion are started at 5 to 6 weeks.

Acute and delayed ligament repair have a very low reported incidence of stiffness. ^{13,30,37,40,64} In a prospective, randomized series comparing modified Brostrom and Chrisman-Snook procedures, Hennrikus et al ³¹ reported that 9% of patients who had the Brostrom procedure thought the repair was too tight as compared with 28% of the tenodesis procedures being perceived equally too tight, but this did not affect subjective results.

The Watson-Jones process has been shown to produce significant subtalar stiffness in xiv% to 68% of patients, ^{4,6,12,27,32,33,49} and to crusade significant loss of dorsiflexion in 20% to 65% of patients. ^3,6,27,33 The Evans procedure is reported to crusade significant subtalar stiffness in 28% to 66% of patients ^{5,seven,8,32,36,55,sixty,63} and is associated with some loss of talocrural joint motion, but less than the Watson-Jones process. The Chrisman-Snook procedure has been reported to cause subtalar stiffness in 48% to 70% of patients, ^32,73 but several series study few problems with ankle move afterwards this reconstruction. ^72,73 When considering these relatively high percentages of subjective and objective stiffness, it is of import to remember that virtually of these series report a successful outcome in lxxx% to 90% of patients, therefore loss of move does non necessarily cause a poor result.

The literature is scant on treatment recommendations for symptomatic stiffness after talocrural joint ligament reconstruction. Colville and Grondel ¹⁷ reported that several patients non included in their information were treated for symptomatic subtalar stiffness later on Watson-Jones or Chrisman-Snook tenodesis procedures. These patients were treated by taking downward the previous ankle ligament reconstruction, then doing an anatomic tenodesis procedure. Subjective issue improved and subtalar joint motion increased. The approach to revision talocrural joint ligament reconstruction for stiffness should be cautious. If the patient is having debilitating symptoms and the reconstruction clearly is too tight on physical exam, it may exist reasonable to exercise a revision anatomic process. If the disability is long standing, or if there is testify of arthrosis of the subtalar joint, revision is unlikely to significantly ameliorate the patient'due south complaints.

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Section Description

Osaretin B. Idusuyi, MD; and G. James Sammarco, MD, Guest Editors

© 2001 Lippincott Williams & Wilkins, Inc.

Which Nerves Can Be Damaged During Ankle Ligament Repair Surgery,

Source: https://journals.lww.com/clinorthop/Fulltext/2001/10000/Complications_of_Lateral_Ankle_Ligament.13.aspx

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