import { ComparisonTable, ContentSection, EvidenceCard, ExamCheatSheet, ExamPearl, ExamWarning, InfoCard, InfoCardGrid, MedicalImage, MnemonicCard, OnePagerSummary, SafetyAlert, Tab, Tabs, VivaScenario, VivaScenarioSection } from '@/components/mdx' # Lateral Ligament Reconstruction Lateral ligament reconstruction addresses chronic lateral ankle instability (CLAI) following failed conservative management. The ATFL is injured in 85% of ankle sprains, with 20-40% developing chronic instability. Gold standard treatment is the **Brostrom procedure** (direct repair) with **Gould modification** (inferior extensor retinaculum reinforcement), achieving 85-95% good-excellent outcomes. Anatomic reconstruction is preferred over non-anatomic procedures, with tenodesis techniques (Chrisman-Snook, Watson-Jones) reserved for failed primary repairs or severe ligamentous laxity. Patient selection requires documentation of mechanical instability (positive anterior drawer and talar tilt), exclusion of hindfoot malalignment, and failure of minimum 3 months conservative therapy. High-yield exam focus: Indications for reconstruction vs repair, Brostrom-Gould technique steps, management of concomitant pathology (hindfoot varus, osteochondral lesions), and complications including stiffness and nerve injury. Examiners expect candidates to distinguish mechanical from functional instability and discuss when to use anatomic vs non-anatomic reconstruction. ### Lateral Ligament Complex The lateral ankle ligament complex consists of three distinct ligaments providing sequential restraint through the range of ankle motion. **Origin**: Anterior border of lateral malleolus (distal fibula) **Insertion**: Talus (lateral body, anterior to lateral articular facet) **Orientation**: Horizontal in neutral position, becomes vertical in plantarflexion **Primary restraint**: Inversion in plantarflexion, anterior translation of talus **Clinical significance**: Most commonly injured ligament (85% of ankle sprains) **Blood supply**: Lateral tarsal artery branches **Origin**: Anterior aspect of lateral malleolus **Insertion**: Lateral calcaneus (tubercle on lateral wall) **Orientation**: Oblique posteroinferior direction **Primary restraint**: Inversion in neutral and dorsiflexion, subtalar inversion **Dual joint restraint**: Crosses both ankle and subtalar joints **Frequency injured**: Second most common (75% when ATFL torn) **Origin**: Posterior border of lateral malleolus (malleolar fossa) **Insertion**: Posterior process of talus (lateral tubercle) **Orientation**: Nearly horizontal **Primary restraint**: Posterior translation of talus, internal rotation **Rarely injured**: Only fails with severe trauma or dislocation **Strongest**: Thickest and strongest of lateral ligaments ### Biomechanical Considerations Lateral ligament reconstruction addresses **chronic lateral ankle instability (CLAI)** following failed conservative management (minimum 3 months). The **ATFL** is injured in 85% of ankle sprains, with 20-40% developing chronic instability. The gold standard is the **Brostrom procedure** (direct anatomic repair) with **Gould modification** (inferior extensor retinaculum reinforcement), achieving 85-95% good-excellent outcomes. Non-anatomic tenodesis techniques (Chrisman-Snook, Watson-Jones) are reserved for failed primary repairs or severe laxity. Critical to distinguish **mechanical instability** (positive anterior drawer greater than 10mm, talar tilt greater than 10° difference) from **functional instability** (subjective giving way without demonstrable laxity) - only mechanical instability requires reconstruction. **Position-dependent function** of lateral ligaments: **P** - Plantarflexion: ATFL taut (primary restraint) **A** - All positions: CFL constant (secondary restraint) **L** - Locked dorsiflexion: ATFL relaxed, CFL maximally taut Clinical application: ATFL tested in plantarflexion (anterior drawer), CFL tested in neutral/dorsiflexion (talar tilt test). The lateral ligaments provide 30-40% of total ankle stability, with osseous anatomy contributing 60-70%. The ATFL resists 80% of inversion force in plantarflexion. Following ATFL disruption, the CFL becomes primary restraint, but isolated CFL insufficiency rarely causes instability. Combined ATFL and CFL injury results in clinically significant chronic instability in 20-40% of cases. ### Progression of Chronic Instability Acute lateral ankle sprain progresses to chronic instability through a pathway of repeated microtrauma and ligamentous attenuation. Initial injury causes ligament elongation (3-5mm) rather than complete disruption in many cases. Repetitive giving way episodes lead to progressive attenuation, capsular laxity, and proprioceptive deficits. Associated pathology develops in 40-70% including osteochondral lesions (35%), peroneal tendon pathology (25%), and sinus tarsi syndrome (20%). ### Mechanical vs Functional Instability ### Surgical Indications **Absolute requirements** for lateral ligament reconstruction: 1. Documented mechanical instability (positive stress tests/imaging) 2. Functional limitation despite 3-6 months conservative therapy 3. Absence of significant hindfoot malalignment 4. Patient motivated for rehabilitation and activity modification Conservative management includes structured physiotherapy focusing on proprioceptive training, peroneal strengthening, and activity modification. Ankle bracing or taping during high-risk activities. Minimum 3 months trial required before considering surgery, extended to 6 months in low-demand patients. ### Contraindications and Patient Factors **Absolute contraindications** include active infection, severe peripheral vascular disease, and Charcot arthropathy. **Relative contraindications** include uncorrected hindfoot varus (greater than 5 degrees), generalized ligamentous laxity (Beighton score greater than 6), poor soft tissue envelope, and unrealistic patient expectations. **Hindfoot varus greater than 5 degrees** must be corrected before or concurrent with lateral ligament reconstruction. Failure to address varus leads to 50-70% recurrence rates. Consider lateral closing wedge calcaneal osteotomy or first metatarsal dorsiflexion osteotomy based on apex of deformity. ### Clinical Examination Systematic examination includes observation for swelling, ecchymosis, and hindfoot alignment (varus predisposes to instability). **Anterior drawer test** performed with ankle in plantarflexion, comparing anterior translation to contralateral side (pathologic if greater than 10mm difference or greater than 3mm absolute). **Talar tilt test** performed in neutral dorsiflexion with inversion stress (pathologic if greater than 10 degrees difference or greater than 15 degrees absolute). **Assessment protocol** for chronic lateral ankle instability: **P** - Proprioception testing (single leg stance, star excursion) **A** - Anterior drawer test (plantarflexion position) **S** - Subtalar motion and stability **T** - Talar tilt test (neutral position) **F** - Functional assessment (hop test, balance) **A** - Alignment (hindfoot varus/valgus) **I** - Impingement signs (anterior, anterolateral) **L** - Laxity general (Beighton score) Systematic approach ensures identification of concomitant pathology requiring concurrent treatment. ### Imaging Protocol Standard radiographs include AP, lateral, and mortise views assessing for talar tilt, anterior tibiotalar distance, and associated pathology (osteophytes, osteochondral lesions). **Stress radiographs** performed with mechanical device applying standardized force: anterior drawer view shows tibiotalar translation, inversion stress view shows talar tilt angle. **MRI indications** include suspected osteochondral lesion, peroneal tendon pathology, sinus tarsi syndrome, or spring ligament injury. T2-weighted sequences show ligament discontinuity, thickening, or waviness indicating chronic injury. Sensitivity 85% for ATFL, 75% for CFL tears. ### Gold Standard Anatomic Repair The modified Brostrom procedure with Gould modification represents the gold standard for primary lateral ligament reconstruction, achieving 85-95% good-excellent outcomes. **Patient Positioning**: Supine with bump under ipsilateral hip, thigh tourniquet, foot over end of table for access. **Incision and Approach**: Curvilinear incision centered over lateral malleolus, extending from tip distally and anteriorly toward sinus tarsi (7-8cm length). Identify and protect superficial peroneal nerve and its dorsal intermediate and medial branches. Develop full-thickness skin flaps to expose lateral malleolus, anterior talofibular ligament remnant, and inferior extensor retinaculum. **ATFL Identification**: Locate ATFL remnant tissue anterior to lateral malleolus, typically appearing thickened, elongated, or scarred. In chronic cases, may appear as sheet-like tissue rather than discrete ligament. Identify talar attachment site anterior to lateral articular facet. **Ligament Repair**: - Excise degenerate tissue from ATFL and CFL remnants - Prepare bone at fibular origin with curette or rongeur for bleeding bed - Place bone anchors (2.8-3.5mm suture anchors) at anatomic ATFL and CFL origins on lateral malleolus - Alternative: Drill holes through lateral malleolus for suture passage - Perform "pants-over-vest" repair: advance ATFL remnant anteriorly and superiorly, secure with interrupted nonabsorbable sutures (0 or 2-0) - Ankle held in neutral dorsiflexion and slight eversion during tie-down - CFL may require separate anchor if involved **Gould Modification**: - Identify inferior extensor retinaculum (strong fascial band from calcaneus to lateral malleolus) - Mobilize lateral portion of retinaculum - Advance and suture over repaired ATFL for reinforcement - Creates double-layer augmentation without altering biomechanics **Closure**: Layered closure with absorbable suture to deep tissues, nonabsorbable or absorbable to skin. Compressive dressing with ankle in neutral position. **Key technical points** examiners expect: 1. Ankle positioned in **neutral dorsiflexion** and **slight eversion** during repair 2. Gould modification uses **inferior extensor retinaculum** (not superior) 3. Avoid overtightening causing **restricted motion** or **subtalar stiffness** 4. Address **concomitant pathology** in same setting (OCL, peroneal pathology) ### Suture Tape Augmentation Technique Internal brace augmentation of Brostrom repair uses high-strength suture tape providing temporary support during ligament healing, potentially allowing accelerated rehabilitation. **Concept**: 2mm suture tape acts as internal "brace" protecting biological repair during healing (6-12 weeks), then serves as secondary stabilizer. Does not replace ligament but augments repair. **Technique Modifications**: - Perform standard Brostrom-Gould repair as described - Place bone anchor at anatomic ATFL origin on distal fibula - Second anchor placed at talar ATFL insertion site - Pass suture tape in anatomic ATFL orientation (horizontal) - Tension with ankle in neutral position - Secure talar anchor, creating adjustable-loop construct - Suture tape lies beneath Brostrom repair **Biomechanical Rationale**: Suture tape has tensile strength of 800-1200N compared to 100-150N for native ATFL. Provides load-sharing during healing without stress-shielding. Gradual creep allows ligament to assume load over time. **Potential Advantages**: - Earlier weight-bearing and range of motion - Protection against catastrophic failure during healing - May reduce re-tear rates in high-demand athletes - Similar outcomes to standard repair in short-term studies **Concerns and Limitations**: - Increased cost (approximately 1500-2000 USD for implants) - Limited long-term data (5 year maximum follow-up) - Potential for stress-shielding or altered proprioception - Not proven superior to standard Brostrom in randomized trials The technique continues to gain popularity, particularly in elite athletes, but remains controversial with insufficient evidence to recommend universally over standard anatomic repair. ### Tenodesis Procedures for Salvage Non-anatomic reconstructions using tendon grafts are reserved for failed primary repairs, severe ligamentous laxity, or poor-quality native tissue. Create static tendon slings rather than recreating normal anatomy. **Chrisman-Snook Procedure**: - Uses half of peroneus brevis tendon - Splits PB longitudinally, keeps distal attachment intact - Routes tendon through fibula, then through calcaneus - Creates both ATFL and CFL replacement - Concern: Sacrifices peroneal strength, may cause stiffness **Watson-Jones Procedure**: - Uses entire peroneus brevis tendon - Routes through fibula and talar neck - Recreates only ATFL function - Historical procedure, rarely performed currently **Allograft Reconstruction**: - Gracilis or semitendinosus allograft - Bone tunnel in fibula and talus/calcaneus - Anatomic positioning mimicking ATFL and CFL - Preserves native tendons - Increasing popularity for revision cases **Indications for Non-Anatomic**: - Failed Brostrom repair (second or third procedure) - Generalized ligamentous laxity (Beighton greater than 6) - Poor-quality tissue preventing anatomic repair - Severe chronic attenuation with no identifiable remnants **Outcomes**: Success rates 75-85%, lower than anatomic repair. Higher rates of stiffness (20-30% vs 5-10%), loss of motion (average 10-15 degrees), and overtightening. Reserved for salvage situations only. ### Protocol Phases **Goals**: Wound healing, edema control, maintain reduction **Immobilization**: Posterior splint or CAM boot, non-weight-bearing **Activities**: Toe wiggling, muscle pump exercises **Precautions**: No inversion, no weight-bearing **Clinic visit**: Suture removal at 10-14 days **Goals**: Restore dorsiflexion/plantarflexion, begin weight-bearing **Immobilization**: CAM boot, progress to 50% weight-bearing by week 6 **Activities**: Active ankle pumps, gentle ROM exercises (no inversion) **Physical therapy**: Commenced week 3-4, focus on swelling reduction **Precautions**: Continue inversion restriction, monitor wound **Goals**: Full weight-bearing, restore strength, proprioception **Immobilization**: Transition to lace-up brace or ASO, full weight-bearing **Activities**: Progressive resistance (theraband), balance exercises **Functional progression**: Elliptical, stationary bike, swimming **Return to work**: Sedentary 6-8 weeks, manual labor 10-12 weeks **Goals**: Return to full activity, prevent re-injury **Criteria**: Full strength, normal ROM, negative functional tests **Progression**: Straight-line jogging, cutting drills, sport-specific **Protection**: Ankle brace recommended for 12 months post-surgery **Success**: 85-95% return to pre-injury activity level **Critical rehabilitation principles**: - No forced inversion for minimum 8 weeks post-operatively - Weight-bearing delayed until 2 weeks (standard Brostrom) or earlier with internal brace - Proprioceptive training essential to prevent recurrence - External ankle support recommended for sports participation for 12 months ### Early Complications **Early post-operative complications** following lateral ligament reconstruction: **S** - Superficial peroneal nerve injury (dysesthesia dorsal foot) **W** - Wound healing problems (dehiscence, infection) **I** - Infection (1-3% incidence) **N** - Numbness lateral ankle (sural nerve branches) **E** - Excessive swelling requiring elevation Recognition and early management prevents progression to chronic issues. **Nerve injury** occurs in 5-10% of cases, most commonly superficial peroneal nerve or intermediate dorsal cutaneous branch. Presents as numbness or dysesthesia over dorsum of foot. Usually neurapraxia resolving spontaneously over 3-6 months. Permanent injury rare (less than 1%) but devastating. Prevention requires meticulous dissection and nerve identification. **Wound complications** include superficial dehiscence (3-5%), deep infection (1-2%), and delayed healing. Risk factors include diabetes, smoking, and peripheral vascular disease. Management includes local wound care for superficial issues, antibiotics plus irrigation and debridement for deep infection. ### Late Complications **Ankle stiffness** is most common late complication, occurring in 10-15% after anatomic repair and 20-30% after non-anatomic procedures. Typically involves loss of dorsiflexion (average 5-10 degrees) or subtalar motion. Prevention includes early range of motion exercises and avoiding overtightening during repair. Treatment with physical therapy, manipulation under anesthesia rarely required. **Recurrent instability** occurs in 5-15% following anatomic repair, 15-25% following non-anatomic reconstruction. Causes include technical failure (inadequate repair), unaddressed hindfoot varus, return to high-risk activities too early, or generalized ligamentous laxity. Management requires identifying underlying cause: revision reconstruction for technical failure, calcaneal osteotomy for varus malalignment. **Chronic pain** without instability affects 5-10% of patients. Differential diagnosis includes sinus tarsi syndrome, subtalar arthritis, peroneal tendinopathy, or complex regional pain syndrome. Requires thorough re-evaluation with advanced imaging (MRI, CT) and targeted injections for diagnosis. Treatment depends on underlying pathology identified. ### Reported Outcomes Success rates for **Brostrom-Gould procedure** range 85-95% with good-excellent patient satisfaction. Return to pre-injury sport level achieved in 80-90% of athletes at average 4-6 months. Recurrence rates 5-10% at 5-year follow-up, increasing to 12-15% at 10 years. **Non-anatomic reconstructions** show lower success rates (75-85%), higher stiffness rates (20-30%), and greater loss of motion. Reserved for salvage situations or failed primary repairs. **Patient-reported outcomes** using AOFAS Ankle-Hindfoot Score average 88-92 points post-operatively (from pre-operative 55-65). FAAM (Foot and Ankle Ability Measure) scores average 85-90% of maximum. Return to work at average 8-10 weeks for sedentary occupations, 12-16 weeks for manual labor. **Q: What is the Broström-Gould procedure for lateral ankle instability?** A: **Broström repair**: Direct repair of attenuated ATFL and CFL with imbrication/shortening. **Gould modification**: Augmentation with **inferior extensor retinaculum** (IER) sutured over repair. Provides additional stability without sacrificing normal anatomy. Preferred first-line surgical treatment. Success rates greater than 85%. **Q: What are the indications for anatomic versus non-anatomic lateral ligament reconstruction?** A: **Anatomic reconstruction** (Broström-Gould): First-line for most patients, preserves normal mechanics. **Non-anatomic tenodesis** (Chrisman-Snook, Watson-Jones): Reserved for revision surgery, **generalized ligamentous laxity**, poor tissue quality, or high-demand athletes. Non-anatomic procedures sacrifice peroneus brevis or plantaris. **Q: What are the components of the lateral ankle ligament complex?** A: **ATFL** (anterior talofibular ligament): Most commonly injured, resists inversion in plantarflexion. **CFL** (calcaneofibular ligament): Crosses both ankle and subtalar joints, resists inversion in neutral/dorsiflexion. **PTFL** (posterior talofibular ligament): Strongest, rarely injured except in severe dislocations. ATFL weakest link. **Q: What is the Chrisman-Snook procedure?** A: **Non-anatomic reconstruction** using split **peroneus brevis tendon** woven through fibula and calcaneus to reconstruct both ATFL and CFL. Sacrifices half of peroneus brevis. Indicated for revision surgery or poor tissue quality. Disadvantage: May restrict subtalar motion and weaken eversion strength. **Q: What clinical tests assess lateral ankle ligament integrity?** A: **Anterior drawer test**: Assesses ATFL - positive if greater than 8mm translation or greater than 3mm asymmetry. **Talar tilt test**: Assesses CFL - positive if greater than 10° or greater than 5° asymmetry compared to contralateral side. Both performed with ankle in **slight plantarflexion** (relaxes Achilles, isolates lateral ligaments). Stress radiographs can quantify. ### Australian Epidemiology and Management Lateral ankle sprains are among the most common sports injuries in Australia, with particularly high incidence in Australian Rules Football, Rugby codes, netball, and basketball. The AFL Injury Surveillance Report consistently identifies ankle injuries as accounting for 10-15% of all injuries across the league. Chronic lateral ankle instability develops in approximately 20-40% of individuals following initial sprain, creating significant ongoing burden in both athletic and general populations. Management of chronic lateral ankle instability in Australia follows international evidence-based guidelines. Initial conservative management including physiotherapy (proprioceptive training and peroneal strengthening), activity modification, and functional bracing is first-line treatment for minimum 3-6 months. Surgical intervention is reserved for patients with documented mechanical instability who have failed adequate conservative therapy. The Brostrom-Gould procedure remains the gold standard, with increasing adoption of internal brace augmentation particularly among elite athletes through sports institutes and private practice settings. Access to surgical management varies between public and private healthcare sectors. In the public system, elective lateral ligament reconstruction typically involves wait times of 6-12 months depending on jurisdiction and clinical priority. Private sector access provides shorter wait times but requires appropriate health fund coverage. Most Australian orthopaedic foot and ankle surgeons have training and experience with anatomic reconstruction techniques, with revision cases and complex reconstructions often referred to subspecialist centres in major metropolitan areas.