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Lateral ligament instability

Lateral ligament injury of the ankle is very common (90) with 1 in 10,000
sustaining the injury per day it is the commonest ligament injury seen by
surgeons. Repeated lateral ligament injuries interfere with normal daily life
(90, 91) and with chronic instability a minor trauma can cause a significant
inversion injury with unpredictable outcome (90, 92).

Surgery to correct lateral ligament instability was described as early as 1949

by Nilsonne who described a peroneus brevis transfer (93). But it was
Brostrom (94) who showed that direct repair of the lateral ligament was
possible even years after acute injury and Hamilton (95) reported 93% good
or excellent results with a modified Brostrom procedure.

With lateral ligament tears, it is the anterior talo-fibular ligament that fails first -
calcaneo fibular ligament rupture is rare (94). A repair/reconstruction ideally
needs to reproduce the ATFL in its anatomic position (96) and this is what a
Brostrom or Hamilton procedure does.

The diagnosis of lateral ligament instability is straightforward - if there is a

history of instability, the lateral ligaments are tender and moving the ankle
demonstrates excessive inversion and an exaggerated anterior draw test.
This is when the foot and talusare translocated anteriorly in the mortis and the
amount of anterior movement recorded and compared with the normal side .
Radiographic lateral stress views can be performed applying set forces of
inversion (90). But results of such instability testing can be questionable if the
calcaneofibular ligament is intact and these patients still have instability (97,
98)

Arthroscopically, there is ballooning of the anterolateral capsule which

appears and feels thinner than normal. One frequently sees scarring of the
lateral gutter and syndesmosis with associated loose bodies or ossicles and
lateral dome or plafond chondral changes.

Treatment is either an open or closed modified Brostrom repair with three

weeks in a below-knee cast then standard physiotherapy. Arthroscopic results
are as good as open (99).

Krips R (100) in 2006 produced an excellent article regarding ankle instability

injuries and reconstruction. Takao M (101) in 2005 clearly demonstrated in
their series of 72 patients that arthroscopy can be used to diagnose the cause
of residual pain after and ankle sprain in most cases that are otherwise
undiagnosable by clinical examination and imaging. Also Okuda R (102) in
2005 interestingly showed in their series of 30 consecutive patients that lateral
ligament reconstruction can be successful regardless of focal chondral lesions
as long as pre-op weight-bearing x-rays do not show any joint space
narrowing.

References
(90) Glasgow M, Jackson A, Jamieson A M, ‘Instability of the ankle after injury
to the lateral ligament’ JBJS 1980; 62B:196
(91) Sefton G K, George J, Fitton J M, McMullen H, ‘Reconstruction of the
anterior talofibular ligament for the treatment of the unstable ankle’ JBJS
1979; 61B:352 .
(92) Hawkins R B, ‘Arthroscopic repair for chronic lateral ankle instability’ In
Guhl J F, ed ‘Foot and ankle arthroscopy’ Thorafore , N J: Slack, 1993: 155.
(93) Nilsonne H, ‘Making a new ligament in ankle sprain’ JBJS 1949 ; 31A :
380
(94) Brostrom L, ‘Sprained ankles : VI. Surgical treatment of ‘chronic’ ligament
ruptures’ Acta Chir Scand 1966 ; 132 : 551
(95) Hamilton W G, Thomson F M, Snow S W, ‘The modified Brostrom
procedure for lateral ankle instability’ Foot Ankle 1993; 14:1
(96) Colville M R, Marder R A, Zarins B ‘Reconstruction of the lateral ankle
ligaments - a biomechanical analysis’ Am J Sports Med 1991 ; 20 :594.
(97) Johnson E E, Markolf K L, ‘The contribution of the anterior talofibular
ligament to ankle joint laxity’ JBJS 1983; 65A:81 .
(98) Ruth C J, ‘The surgical treatment of the fibular collateral ligament of the
ankle’ JBJS 1961; 43A:229
(99) Gollehon D L, Drez D, ‘Ankle arthroscopy - approaches and technique’
Orthopaedics 1983; 6:1150
(100) Krips R, de Vries J, van Dijk C N, ‘Ankle Instability’ Foot and Ankle
Clinics 2006; 11:2; 311-29
(101) Takao M, UchioY, Naito K, Fukazawa I, Ochi M, ‘Arthroscopic
assessment for intra-articular disorders in residual ankle disability after sprain’
Am J Sports Med 2005; 33:5; 686-92
(102) Okuda R, Kinoshite M, Morikawa J, Yasuda T, Abe M, ‘Arthroscopic
ankle findings in chronic ankle instability: do focal chondral lesions influence
the results of ligament reconstruction?’ Am J Sports Med 2005; 33:1; 35-42

Simon Moyes