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Arthroscopic ligament repair shows promise

By Terry Stanton

Small group of patients has positive results

Although, ligament reconstruction in the shoulder and knee is increasingly performed arthroscopically, open surgery has prevailed in repair of the lateral ankle ligament.

Peter G. Mangone, MD, notes that the open approach remains the standard “despite the fact that ankle arthroscopy has become more common.” Dr. Mangone has developed an arthroscopic Brostrom-Gould–type procedure for lateral ankle ligament reconstruction, and at the 2010 American Orthopaedic Foot & Ankle Society annual meeting, he presented his results.

Dr. Mangone said that diagnostic arthroscopy led him to develop and perform the technique. “Increasing evidence indicates that arthroscopic examination at the time of bilateral ligament reconstruction is appropriate due to intra-articular pathology,” he said. “About 3 years ago, I was sitting in on an arthroscopic case to do a ligament reconstruction. I was looking at the lateral capsule and the ligament, and I thought, ‘Why don’t I just fix it while I’m here?’” He subsequently developed his technique based on cadaveric dissection.

From 2007 to 2009, eight patients underwent lateral ligament reconstruction by the arthroscopic technique. Nonsurgical management had been unsuccessful, and patients were judged eligible if they met the criteria for a normal Brostrum-Gould–type reconstruction. Patients who required tendon graft–type reconstruction were excluded from the study.

Technique
The procedure is performed with a popliteal block plus either general anesthesia or monitored anesthesia care and a noninvasive distractor. After the arthroscopic examination, débridement is performed through two normal portals. The lateral gutter is débrided more extensively to visualize the anterior distal fibula, the lateral capsular structures, and the anterior talofibular ligament (ATFL). Dr. Mangone said that “a 30-degree scope is fine” for this procedure.

Two bioabsorbable bone anchors are placed in the anterior inferior fibula, using the anterolateral portal under direct arthroscopic visualization. The first anchor is placed distally, and the second is placed slightly superior (Fig. 1, A). The first anchor is run through the inferior extensor retinaculum, and the second through the ATFL and capsule and the inferior extensor retinaculum. The sutures are passed through with a sharp-tipped suture passer and brought out through the skin over the anterolateral ankle/foot (Fig. 1, B).

FAS Lateral ligament_1.gif

FAS Lateral ligament_2.gif

Fig. 1 A, Bone anchors are placed in the anterior inferior fibula through the anterolateral portal under direct arthroscopic visualization, and B, a sharp-tipped suture passer (a microsuture lasso) is used with the “outside-in” technique. (Reprinted with permissions from Corte-Real NM, Moreira RM: Arthroscopic repair of chronic lateral ankle instability. Foot Ankle Int 2009;30(3):213-217.)

A small incision is then made so that the sutures can be tied down. The ankle is taken out of distraction and is held in slight dorsiflexion and eversion while the sutures are tied. In five of the cases, Dr. Mangone said, an additional suture was passed through the fibular periosteum and into the inferior extensor retinaculum through a small incision (<1 cm) to reinforce the repair.

After the procedure, patients were placed in a short-leg partial weightbearing cast for 4 to 6 weeks, after which a lace-up style ankle gauntlet brace was worn for the next 6 to 12 weeks. (Dr. Mangone noted that he has shortened the cast time to 4 weeks.)

Results
At 3 months after surgery, all the patients demonstrated subjective improvement in their instability compared with their preoperative symptoms. Seven of eight had negative anterior drawer tests postoperatively, and five of eight had a negative tilt test (two patients had a trace positive tilt, and one had a 1+ tilt result). All patients reported no pain at the 3-month follow-up.

Three of eight patients did report mild instability symptoms, but all experienced subjective improvement compared with their preoperative status. No major wound or nerve complications occurred. Because none of the patients was a high-performance athlete, an assessment for return to significant athletic activity was not done.

By 4 to 6 months after surgery, all patients were ambulating without brace support, although Dr. Mangone said that for patients who do hiking or similar activities, he recommends wearing an ASO (ankle stabilizing orthosis) brace or a high-top hiking boot for 6 to 12 months after surgery.

New era?
Dr. Mangone described these initial results as “promising” and said that they—along with the results of a previous study by Corte-Real and Moreira—support the feasibility of the arthroscopic approach. He and a colleague continue to perform the procedure and evaluate results.

“In these select patients, this technique allowed for successful reconstruction of the lateral angle ligament complex ligaments through much smaller incisions than in conventional methods,” concluded Dr. Mangone. “I think we are in the dawn of a new era, which requires further prospective studies comparing arthroscopic and open procedures, along with mechanical studies.”

Disclosure information: Dr. Mangone—Arthrex.

Terry Stanton is senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Bottom Line

  • Although arthroscopy is used diagnostically in lateral ankle ligament reconstruction, open surgery remains the standard for repair.
  • A single surgeon developed an arthroscopic technique and reported on its results in eight patients.
  • All of the patients in this small study showed improvement, with no surgically related complications.
  • Further studies are warranted to determine the effectiveness of arthroscopic repair of the lateral ligament.

AAOS Now
November 2010 Issue
http://www.aaos.org/news/aaosnow/nov10/clinical5.asp