Title: Extensor Retinaculum Augmentation Reinforces Anterior Talofibular Ligament Repair
Authors: Aydogan U, Glisson R, Nunley J
Source: Clinical Orthopedics and Related Research 2006; 442:210-215
PODIATRIC RELEVANCE:
The foot and ankle specialist often utilizes primary repair for the treatment of ATFL injury. The modification described by Gould et al incorporates the inferior extensor retinaculum (IER) in the repair. The podiatric and orthopedic literature has never studied whether this procedure is necessary in primary repair of the ATFL. Due to the more extensive dissection and additional time added to the case it is worthy of investigation.
METHODS:
Ten pairs of fresh frozen cadaveric feet were obtained. Matched pairs of ankles were evaluated to compare the standard Brostrom repair with the Brostrom and Gould modification. To reproduce the mechanism of inversion ankle injuries the ankles were positioned at 20 degrees of plantarflexion and the foot 15 degrees internally rotated. The ankle was then inverted from 0 degrees to 40 degrees at 10 degrees per second. At five degree increments of inversion torque data was collected. Torque curves were examined for incongruency and corresponding suture tearing through the soft tissue by visualization. A correspondence of suture pull out and incongruency of the torque curve was indicative of failure.
RESULTS:
The net torque (resistance to inversion) was greater at 5, 10, 15, 20 and 25 degrees of ankle inversion for those limbs that received the IER augmentation. All of the ATFL ligaments failed at similar ankle inversion angles regardless of the procedure performed. However, the ankles repaired with the Gould modification tore at a greater force. The final significant result is that the IER repair failed before the ATFL began tearing. However, the IER did not completely fail until the ATFL completely failed.
COMMENTS:
In our surgical treatment of pathology we should provide the best treatment while limiting any unnecessary procedures. This study provides a good basis for the foot and ankle surgeon to incorporate the IER into the primary ATFL repair. A few important conclusions can be made from this cadaveric study. First, the Gould modification does provide increased resistance to ankle inversion. Second, the modification will not provide any greater inversion before failure than the primary ATFL repair. This study does have some limitations as mentioned by the authors. The inherent nature of a cadaveric study is a reason to be cautious in interpreting the data. For example, in the cadaveric limb the lateral ankle complex is not functioning in a dynamic environment with muscles and tendons to assist in stabilization. In addition, the repair depends on the sutures alone and not on healing of the repaired tissue. This paper is the first to show that augmentation of the Brostrum procedure is protective to the ATFL and should be strongly considered when doing a primary repair of the ATFL.
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Disclaimer:
Scientific Abstract Monthly postings are submitted by podiatric surgical residents. The ideas presented are not the opinions of the American College of Foot and Ankle Surgeons (ACFAS), nor are they presented as facts. ACFAS presents this information without any warranty of any kind, expressed or implied, and is not liable for its accuracy nor for any loss or damage caused by the user's reliance on information obtained in these areas.