Correction of Lateral Ankle Instability

CHAPTER 12 The Modified Evans Ankle Stabiltzatton For Correction Of Lateral Ankle Instability

James L. Bowchard, DPM.

INTRODUCTION stick incision on the lateral aspect of the ankle. Due to the amount of dissection and necessity of One of the most common injuries of the lower securing the transferred tendon graft to the body of extremity is the lateraL ankle ligamentous disrup- the calcaneus in a trephine hole, prolonged immo- tion. In recent years, with greater emphasis on bilization and postoperative rehabilitation, is physical fitness, the chronically painful and unsta- necessary which complicates the postoperative ble lateral ankle is an increasing common clinicai course by prolonging the patient's retuJn to normal finding presenting to the podiatrist's office. In daiiy activities. many cases, these potentially disabling injuries are Figure 1 demonstrates the single djoint changes commonly seen in nous at its distal insertion. Due to the extensive the chronically painful and unstable ankle. Most dissection and rehabilitation time with the conven- lateral ankle ligamentous injuries may be consid- tional SPBLAS technique, members of the Podiatry ered a stage one supination-adduction injury by Institute have modified the procedure in recent the Lauge-Hansen classification. Subsequent inver- years to combine the deep fascia incisions at sion injuries to an unstable ankle face the risk of a stage two supination-adduction injury, with associated medial malleolar fracture and increased incidence of degenerative joint disease or post traumatic arthritis. Historically, ankle stabllizatron surgical techniques have primarily been devised to coffect either a single ligamentous repair involving the anterior talofibular ligament, or a double ligamentous repair involving both the anterior talofibular ligament and the calcaneofibular ligament. The split peroneus brevis lateral ankle stabilization (SPBIAS) has proven to be a dependable surgical technique fcsr stabilization of the unstable ankle by the members of the Podiatry Institute over the past twenty years. The SPBLAS is a modification of many other previously described lateral ankle stabilization techniques utilizing the peroneus brevis tendon as tendon graft to replace the weakened or injured anterior talofibular ligament Figure 1. The single skin incision for the and calcaneofibular ligament, This is usually SPBIAS procedure. accomplished through a single curuilinear hockey CHAPTER 12 5l selected areas for transfer of the peroneus brevis tendon, utilizing smaller incisions in the deep fascia rather than complete dissection through its entire length. This has resulted in decreased postoperative pain and swelling, but no significant effect on the patient's early return to normal activity. A consistent drawback to the procedure has been the arthrotomy of the ankle, with inspection of the joint surface and examination of the laterdr collateral ligaments of the ankle, which is required during the excessive dissection and exposure. The author has used with success, over the last seventeen years, a modified three skin incision approach, avoiding the long hockey stick incision charuclerized by extensive lateral dissection of the ankle. The three incision approach includes a distal incision over the base of the 5th metatarsal at the insertion of the peroneus brevis tendon. This is performed in a linear fashion following the tendon's insertion, approximately 2.5 cm to 3.0 cm in Figure 2. Skin incision for modifled Evans. length. The second incision is an oblique incision following the skin lines at the 1evel of the anterior inferior aspect of the head of the fibular. This is used to isolate the tip of the fibula, which is required for transfer of the tendon through a trephine hole in the fibula. This incision is approximately 4.0 cm in length, and can be extended inferiorly if reattachment of the peroneus brevis tendon graft to the body of the calcaneus is neces- szry, as is often required with more severe ligamentous disruptions. The third incision is a linear incision following the posterior coLlrse of the fibula. Figure 2 demonstrates the placement of the three incision technique, particulady when com- bined with the modified Evans procedure. Patients typicaily have decreased pain and swelling, and quicker rehabilitation due to the decreased amount Figure 3. Split peroneus brevis lateral ankle stabilizing procedure. of surgical dissection.

HISTORICAL REVIEW OF THE graft through a canal in the fibula, then through the SURGICAL TECHN]-IQUES calcaneus and lateral aspect of the talus. A strip of fascia is utilized covering the double ligament Double Ligamentous Lateral Ankle Repairs repair (Fig. 4). Christman and Shook used half of the peroneus brevis tendon as a modification of Figure 3 demonstrates the SPBLAS procedure, with the Elmslie procedure leaving the half of the per- transfer of one half of the peroneus brevis tendon oneus brevis tendon intact. The peroneus brevis through the fibula, and then attachment to the tendon is transferred through a canal in the fibula, body of the calcaneus through a trephine hole at reattached to the Tateral aspect of the calcaneus, the calcaneofibular ligament insertion site. Elmslie and then to the peroneus brevis tendon (Fig. 5). utilized a doubleligament repair through a similar Hambly modified the procedure by splitting long hockey stick incision, transferring the tendon the peroneus iongus rather than the peroneus 52 CHAPTER 12

Figure 4. Elmslie doubleJigament reconstl'Ltction. Ftgure 5. Christman and Shook lateral ankle stabilization

brevis. The tendon is passed through the fibula, sutured through the lateral aspect of the talus, and then inserted into the calcaneofibular ligament. This modification also utilized a long hockey stick incision to expose the lateral aspect of the ankle (Fig. 6). Whinfield described a procedure for lateral ankle stabilization similar to that of Hambly, however, the peroneus brevis is used instead of the peroneus longus tendon. The double ligament ankle stabilization, described by \7hinfield, is illus- traled in Figure 7. There have been various other double hga- ment lateral ankle repairs reported in the literature. The skin incision and dissection necessary for Figure 6. Hambly's lateral ligament reconstmction procedure exposure, in most of these cases, ts charactertzed by postoperative pain, swelling, and increased rehabilitation.

Single Ligamentous Lateral Ankle Repair '$Tatson-Jones utilized the entire peroneus brevis tendon, leaving its distal insertion intact. The tendon is passed through a canal in the fibula, into the neck of the talus, back through the fibula, and then attached to itself posteriorly at the level of the fibula. Figure B demonstrates the transfer of the entire peroneus brevis tendon, which requires extensive dissection to obtain exposure for transfer of the tendon. Lee modified the Vatson-Jones procedure due to the technical difficulty in obtaining adequate Flgure doubleJigament lateral ankle stabilization tendon length for transfer. The Lee modification 7.'$Thinfield utilizes the entire peroneus brevis tendon, passing it posterior to anterior through a canal in the fibula, CHAPTER 12 53 and suturing the peroneus brevis tendon distally PREOPERATIVE CONSIDERAIION and inferiorly upon itself (Fig. 9). Nilsonne detached the peroneus brevis at the A thorough history of the nature of the ankle injury musculotendinous junction, passed the tendon is essential for proper diagnosis and treatment of through a canal in the fibula, and realtached it into lateral ankle instability. Patients with complaints of a subperiosteal groove in the lateral aspect of the daily ankle pain, swelling, or instability which fibula. The remaining proximal portion of the per- interferes with daily activity or athletic perfor- oneus brevis muscle is attached to the peroneus martce are candidates for lateral ankle ligamentous longus tendon, as outlined in Figure 10. surgical correction. In most cases, surgical correc-

Figure 8. \Watson-Jones lateral ankle ligament repair. Flgure 9. Lee lateral ankle stabilization

In addition to the peroneus brevis and peroneus longus tendon transfer, many investigators have utilized portions of the Achilles and plantaris tendons for stabllization of the ankle. These procedures require additional extensive dissection and postoperative rehabilitation. Evans, after detaching the peroneus brevis tendon from the musculotendinous junction proximally, sutured the remaining muscle belly of the peroneus brevis to the peroneus longus tendon. \trith the peroneus brevis tendon inseftion intact, the tendon was then passed through a canal in the fibula, attaching the transferred tendon to the posterior aspect of the distal fibula (Fig. 11). The Evans Figure 10. Nilsonne lateral ankle ligament repair. procedure has been modified by members of the Podiatry Institute utilizing one half of the peroneus brevis tendon transferred through a canal in the tion is reserwed for patients with disabling distal fibular and inserted into the lateral calcaneus. recurrent instabiliry, where consetwative therapy The author has modified the conventional Evans has failed. procedure, utilizing three separate skin and deep Patients with a chronically injured lateral fascia incisions, thus decreasing the amount of sur- ankle will usually present with a palpable dell or gical dissection, postoperative edema, patn, and spongy area along the course of the anterior rehabilitation. talofibular ligament and calcaneofibular ligament, with associated pain and tenderness. Pain on inver- CHAPTER. 12

Figure 11. Er.ans lateral ankle stabilization.

sion of the ankle and subtalar joints is a frequent finding with associated lateral instability. Subluxation or dislocation of the peroneal tendons Figure 12. A positiYe stress inversion must also be suspected in severe injuries. radiograph. Typically, conventional ankle radiographic findings are negative, except for occasional osteoarthritic changes. A small ioose osseous body, from ligamentous ar,ulsions, is often noted on radiographic evaluation. Stress radiographs are often the greatest aid in determining the degree of chronic lateral ankle instability. Stressed radiographs of the ankle con- ventionally include the stress inversion and anterior drawer tests. Stress radiographs may be performed bilaterally for comparison purposes, as patients with ligamentous laxily may normally present with excessive inversion of the ank1e. sometimes in excess of 18-20 degrees. Thus, a patient with no history of ankle injury may have a talar tilt of 18-20 degrees secondary to ligamentous laxity. Most investigators agree that a lalar tilt dif- ference of 18 degrees or more is indicative of double ligamentous injury to the lateral ankle (Fig. 12). The stress inversion view is relied upon as a more accurate diagnostic test, in comparison to the Figure 13. A positive anterior-dfaq,er sign. anterior draw-er, for assessment of ankle stability. The anterior drawer test is not relied upon as much as the stress inversion test. Anterior displacement of the talus greater than 4.0 mm is considered to be tion should not be considered an absoiute con- a positive result, indicating lateral ligamentous traindication to stabilization. injury (Fig. 13). Occasionally, stress testing of the In more recent years, magnetic resonance ankle may be negative, despite the patient's con- imaging (MRI), has been of great benefit in deter- tinued instability and need for ankle stabtlization, mining the extent of ligamentous injury to the Therefore, a negative stress radiographic examina- lateral ankle. Prior to the development of MRI, CHAPTER 12 55 ankle arthrograms have been used to demonstrate incisions after performing the conventional long the extent of lateral ankle injury, especially when hockey stick incision. Although findings suggest ankle capsule rupture or peroneal tendon subluxa- decreased swelling and edema, the modified Evans tion/dislocation is present. procedure is less traumatic since it does not involve transfer of the peroneus tendon to a SURGICAL TECHNIQUE trephine hole in the body of the calcaneus. Typically, the deep fascia is incised along the com- The patient is placed on the operating room table plete course of the lateral hockey stick incision. in alaleral position with the use of a vacuum pack. The peroneal retinaculum is also preserued A pneumatic thigh tourniquet is often used to facil- during dissection to avoid complications such itate hemostasis, however, the infiltration of a local as postoperative peroneal tendosynovitis. At the anesthetic with epinephrine (1 to 200,000) may be proximal incision posterior to the fibula, the utilized as an alternative to the tourniquet. The myotendinous junction of the peroneus brevis ten- proper positioning of the patient facilitates dissec- don is identified and retracted. Approximately 3/4 tion and decreases surgical time. Care must be of the myotendinous junction at this level is incised taken in positioning the patient to avoid compres- and prepared for splitting of the peroneus brevis sion at the head of the fibula (common peroneal tendon into two pofiions. The released end of the nerve) and lateral malleolus by using appropriate tendon is then secured with a 2-0 absorbable padding. suture. Attention is then directed to the distal inci- The surgical approach to the modified Evans sion where a tendon passer or double braided procedure is performed through three separate stainless steel wire is introduced under the tendon skin incisions rather than the conventional 15-77 sheath of the peroneus brevis tendon, extending cm hockey stick incision which extends from the proximally around the lateral ankle to the posterior base of the 5th metatarsal to above the ankle joint. aspect of the distal7/3 of the fibula. At this point, The anatomic landmarks for the three incisions are the suture-tagged peroneus brevis myotendon is outlined with a skin scribe, and include the base of secured to the wireloop or tendon passer, and the 5th metatarsal, distal 1,/3 of the fibula, and the withdrawn distally, thereby dividing the peroneus anterior lateral ankle joint and calcaneus. The pro- brevis tendon into lwo portions. The superior por- posed length of the peroneus brevis tendon graft tion of the tendon is passed sub-periosteally to the can be estimated with the use of sterile umbilical level of the inferior margin of the fibula, where an tape to outline its course. Accurate placement of osseous canal is made with a small 4.0 mm the skin incisions is necessary to provide adequate trephine. Care is taken to direct the trephine hole exposure to the underlying structures. in the center of the lateral malleolus to avoid injury The incisions are deepened through the sub- to the ankle joint, exiting posteriorly in the middle cutaneous layers to the level of the deep fascia portion of the distal fibula. The angle of the utilizing the conventional concepts of anatomical osseous channel is intended to approximate the dissection. Hemostasis is achieved with either position of the anterior talofibular ligament. suture ligation of larger vessels or electric cautery. Occasionally an arthrotomy will be performed in The sural nen/e is protected throughout the proce- conjunction with the procedure, to inspect the dure, and is usually encountered when the middle articular surface of the talofibular joint, and to rein- incision is extended distally and inferiorly towards force the ankle joint capsule during closure of the the calcaneus. Deep fascia remains intact except middle incision. In the modified Evans procedure, for the areas of potential transfer, including splir half of the peroneus brevis tendon is attached to ting of the tendon distally at the insertion at the the posterior aspect of the fibula, and then reat- base of the 5th metatarsal, rerouting of the tendon tached proximally to the remaining myotendinous at the anterior inferior aspect of the lateral malleo- junction of the peroneus brevis. With this tech- lus, and securing of the tendon to the posterior nique, there are three points of fixation of the aspect of the fibula following the transfer through tendon graft. The first anchor point is at the ante- the osseous canal. rior inferior margin of the distal aspect of the Kalish and DiNapoli (1989) described the fibula, which is secured with 2-0 non-absorbable SPBLAS procedure utilizing three small deep fascia suture. The second point of attachment is at the 56 CHAPTER 12 posterior fibula, following transfer of the tendon Although the procedure can be performed on through the osseous canal, also with 2-0 non an outpatient basis, overnight admission is recom- absorbable suture. Finally, proximal reattachment mended. Removal of surgical drains and the of the peroneus brevis tendon to the myotendinous application of a below the knee weight-bearing junction is performed with 2-0 non- absorbable cast can be preformed prior to discharge. suture. During this procedure, care is taken to hold The patient is usually casted for 4 to 5 weeks the foot in slight eversion to allow for an appropri- and following cast removal, range of motion exer- ate amount of correction. After securing the cises are resumed. The patient will benefit from the transferred tendon graft, stability of the rearfoot and use of high-top shoes following cast removal for ankle can be appreciated. Howeveq securing of the added stability, during the final stages of healing. tendon graft under extreme tension canlead to sub- In many cases, an ankle splint or air cast may be talar joint pain, stiffness, and eventual arthritis. utilized. A modification of the SPBLAS procedure is often employed to reinforce a weakened or rup- COMPLICAIONS tured calcaneofibular ligament. This entails transfer of the tendon into the laterul body of the calcaneus The most common postoperative complication fol- and requires lengthening of the middle incision lowing lateral ankle stabilization is a transient inferiorly to the level of the calcaneus. In this case, tenosynovitis of the peroneal tendons around the a trephine is used to remove a cofiicocancellous ankle joint. This accounts for L50/o of the postoper- plug of bone from the lateral body of the calca- ative complaints. Transient tenosynovitis can be neus, approximately 1,.5-2.5 cm in depth. The free effectively treated with compression, ice, rest and end of the tendon is inserted into the trephine immobilization. On occasion, nonsteroidal anti- hole, and the bone is packed around the tendon's inflammatory drugs (NSAIDs) are L\tilized In more new inseftion in the lateral calcaneus. Thus, the symptomatic cases of tenosynovitis, local injections peroneus brevis tendon is used for reconstruction of dexamethasone phosphate may be beneficial. of the calcaneo fibular ligament. The surgeon must Another frequent postoperative finding is anticipate the need for additional length of the per- swelling related to the surgical procedure. Post oneal brevis tendon by lengthening the proximal operative swelling and inflammation are normal incision. During surgery, sterile saline is used to but excessive swelling and inflammation should be moisten the tissues, particrlarly the tendons, to addressed. Excessive swelling and edema may pro- avoid dehydration of these structures. Care is also long the rehabilitation process. The applications of taken to avoid contact of the tendinous st nctures rest, ice, compression and elevation are important with the skin, thus reducing the chance of a post- in treating postoperative edema, which may take operative infection. A unique characteristic of both four to six months to resolve in more severe cases. the SPBLAS and modified Evans procedures is that Other complications include continued ankle insta- the split tendon is routed in a subperiosteal- bility, hypertrophic scarring, wound dehiscence, subcapsular fashion, extending from the base of infection, and sural nerve entrapment or neuritis. the 5th metatarsal along the lateral aspect of the These are tate complications, but the patient talus, and exiting at the anterior inferior margin of should be informed of these potential complica- the fibula, at the site of the trephine hole. tions from a risk management concern. The deep fascia incisions are then closed The transferred tendon graft can potentially using 2-0 or 3-0 absorbable suture. In most cases, be placed under too much tension, holding the a closed section drain is utilized at the middle or foot in a position of eversion, causing pain and second incision, at the level of the ankle joint. limitation of subtalar or ankle joint motion. In these Superficial fascia is closed with 3-0 or 4-O suture, cases, a "Z-plasqr" lengthening or release of the with special care taken to avoid trauma to the sural transferred tendon can relieve symptoms and nerve. Finally, the skin is closed with either 4-0 or reverse the condition if treated in the early stages. 5-0 absorbable or non-absorbable suture, followed Although rare, fracture of the fibula or violation of by the application of steri-strips. A moist saline the talofibular articulalion has been repofted in the dressing is applied, and the ankle is stabilized with literature. This usually occurs during placement of a compression dressing aod/or cast. the trephine hole in the fibular canaL Should this -I2 CHAPTER 57 occur, open reduction and internal fixation may be ified Evans procedure to the conventional SPBIAS necessary, of in more severe cases, ankle fusion procedure. The postoperative course involved four may be necessary. Transient dysesthesias and to six weeks of casting rather than sk to eight paraesthesias associated with sural nerve entrap- weeks of casting, with less need for aggressive ment have been reported, as well as postoperative physical therapy. Patients, in most cases, were able sural nerve neuroma formation. These conditions to resume prior activity within twelve to fourteen can be readily prevented by careful surgical dis- weeks, and in some cases from eight to fwelve section and preservation of the nele during the weeks. sufgery. SUMMARY RESULTS The modified three incision approach for perfor- In a retrospective study of 25 cases involving the mance of the SPBLAS and modified Evans modified Evans lateral ankle stabilization over the procedure has been successfully utilized by mem- last 77 yearc1 95o/o of the patients reported good to bers of the Podiatry Institute over the last 77 years. excellent results and their willingness to undergo Through the modified three incision approach, the the surgery if they were given the choice again. single ligamentous disruption (talofibular iigament) These patients were able to resume their normal or the double ligamentous injury (anterior talofibu- activity prior to the surgery. There were no patients lar and calcaneofibular ligaments) can be who had recurrent symptoms of ankle instability, addressed. In more severe cases of ligamentous however, it should be noted that the procedure disruption involving both ligaments, the modified was not performed on patients with a talar tllt Evans procedure may prove to be inefficient in greater than 72-75 degrees, or symptoms suggest- controlling ankle instability, thus necessitating sim- ing calcaneofibular ligament disruption. ilar procedures such as the SPBLAS technique Transient tenosynovitis was the most common designed for double ligamentous disruption. Early postoperative finding repofted, and three of the diagnosis and assessment of the ankle injury is patients in the sample responded well to local essential in determining the optimal surgical treatment consisting of rest, ice, compression, and results. elevation. In addition, one of the cases of transient tenosynovitis required a series of three injections of BIBLIOGRAPTTY dexamethasone phosphate. 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