1/6/12 - Ankle School

So - being who I am - I have to go and find out everything I can about these procedures that I will be enduring - would you like to see some info I found? Here ya go...

Tenodesis Procedures
Other procedures, are mainly tenodesis procedures. Four have been extensively used and described in the literature: the Evans, Watson-Jones, Larsen, and Chrisman-Snook procedures. These procedures focus on harvesting all or part of the peroneus brevis and then rerouting the tendon through various bone tunnels, thereby creating a tenodesis of the ankle or reconstructing the ATFL or CFL. Indications for these augmented types of reconstruction are as follows:

•The ATFL and CFL are so disrupted and frayed that they cannot be repaired primarily.
•Hypermobility of the subtalar joint is present.
•The patient has had previously unsuccessful reconstruction of the ankle.

The technique for the overall approach for each of these procedures is essentially the same. A longitudinal incision is made running just posterior to the prominence of the lateral malleolus. The incision is then extended to allow harvesting of the peroneus brevis tendon. Before harvesting the tendon, the joint is inspected and debrided if necessary. Occasionally, the ATFL and/or CFL are avulsed from the fibula with a piece of bone. This so-called os subfibulare should be excised.

Maintain the integrity of the superior peroneal retinaculum upon exposure of the peroneus brevis tendon. The anterior one third of the tendon is isolated distally and split from the distal position to the musculoskeletal junction. This tendon portion is transected at its proximal aspect. A drill hole is made through the distal fibula, and the split portion of the peroneus brevis is passed through this hole. The tendon is tensioned with the foot in mild plantarflexion and eversion.

The Evans procedure provides stability that is a result of the ATFL and CFL but not anatomically or mechanically. The peroneus brevis tendon is anchored to the fibula, indirectly limiting inversion of the ankle and anterior talar translation, while also limiting motion of the subtalar joint.

The Watson-Jones procedure (remember Plan A) reconstructs the ATFL but not the CFL. This technique makes use of the Evans tenodesis. One important addition, however, is that the peroneus brevis graft is routed anteriorly through the talar neck to reconstruct the ATFL.

Larsen rerouted the peroneus brevis tendon from the fifth metatarsal base into the fibula and then back down into the calcaneus. The proximal part of the tendon is sutured to the peroneus longus.

The Chrisman-Snook procedure, (remember Plan B) most commonly used for subtalar instability, involves using half of the longitudinally divided peroneus brevis tendon to substitute or reconstruct the CFL. In this procedure, the peroneus brevis graft is brought through the fibula from anterior to posterior to reconstruct the ATFL. It is then brought posteriorly and inferiorly to the calcaneus in a weave pattern to reconstruct the CFL. The Chrisman-Snook procedure, although technically demanding, has been repeatedly demonstrated to produce satisfactory stability to those patients who have a talotibial and combined talotibial and talocalcaneal instability.

Hey wait a minute....this is starting to sound like a Frankenstein movie...

Chronic Instability Operative Repair Outcomes
These procedures vary greatly in the ability to correct subtalar instability. A review of the literature shows that the Watson-Jones procedure is associated with subjective instability 20-90% of the time, and the Evans procedure, 20-33%. In addition, with the Evans procedure, a persistent anterior drawer sign is found in 45-60% of patients. In the Chrisman-Snook procedure, 13-30% of patients had subjective persistent instability. Decreased inversion is common with all these procedures. In each procedure, a specific weave pattern (referring to the manner in which the peroneus brevis tendon is routed through the drill holes) is used.

Surgical therapy: According to a 1999 review by Safran, Zachazewski, and Benedetti, more than 20 different delayed surgical procedures are available for chronic ankle instability and sprains. Most of these procedures are reconstructive in nature and frequently involve tenodesis between the lateral malleolus and calcaneus, talar head, and/or the fifth metatarsal. All of these procedures use the peroneus brevis and/or longus, Achilles tendon, or fascia lata [a covering on a muscle in the thigh]. None really restore true anatomy.

Hey I get to be even more different than others! - and maybe I will have super springs for ankles after all of this - LOL - hey you never know...

Well - atleast now I feel a little more in the know...