SLR - July 2015 - Amber Wibbels

Reconstruction of the Lateral Ligaments of the Ankle Using a Periosteal Flap in Children and Teenagers: A Midterm Follow-up Survey

Reference: Mathieu PA, Marcheix PS, Vacquerie V, Dijoux P, Mabit C, Fourcade L. Reconstruction of the Lateral Ligaments of the Ankle Using a Periosteal Flap in Children and Teenagers: A Midterm Follow-up Survey. J Pediatr Orthop. 2015 July-Aug; 35(5):511-5.

Scientific Literature Review

Reviewed By: Amber Wibbels, DPM
Residency Program: Pinnacle Health Hospitals, Harrisburg PA

Podiatric Relevance: Although rare, the rate of chronic lateral ankle instability has been on the rise in children and teenagers with repeated sprains leading to ankle instability in about 1/5 of these cases. Few studies have been published regarding the surgical management of this population with the current gold standard of treatment consisting of a repair sacrificing the peroneus brevis tendon. This study described and evaluated a new method for reconstructing the lateral ankle ligaments by utilizing a regional periosteal flap obtained from the lateral malleolus.

Methods: A single-center, retrospective study was performed on 14 patients under the age of 16 (mean age of 12.7) who had a history of >6months of chronic ankle instability (mean number of 6 sprains per patient) and underwent an anterior talofibular ligament reconstruction by a fibular periosteal flap, between January 2009 and December 2012 at Limoges University Hospital, France. A periosteal flap was collected from the lateral malleolus passed through the neck of the talus and sutured upon itself to recreate the anterior talofibular ligament.  Postoperatively patients were in a cast for 45 days followed by physiotherapy for 2 months.  Radiographic assessment included calculation of the tibiotalar tilt and anterior translation of the talus. Functional assessment included American Orthopedic Foot and Ankle Society (AOFAS) scores as well as Gould’s criteria.  

Results: The tibiotalar tilt improved from 14 degrees (range of 10-18 degrees) preoperatively to 4 degrees (range 2-10 degrees) after surgery. The anterior translation of the talus improved from 11mm (range 12 to 8mm) preoperatively to 2mm (range 1 to 4mm) after surgery.  Both radiographic measurements were statistically significant (P < 0.001). Postoperative radiographs taken at 2months, 6months, 1 year and 2 years revealed no epiphysiodesis of the lateral malleolus, transplant ossification or heterotopic bone formation. AOFAS scores improved from 61 points (range 46 to 74) preoperatively to 95 points (range 79 to 100) following surgery which was statistically significant (P < 0.001).  Gould’s classification revealed 11 excellent, 2 good, 1 average and no bad results. Complications included 3 cases of superficial necrosis and 3 cases of paresthesia in the superficial peroneal nerve which all resolved without sequelae.   

Conclusion: The authors of this study suggest a new method of surgical repair for chronic lateral ankle instability in children and teenagers. The current gold standard method of repair via peroneus brevis tendon in pediatrics has lead to complications such as decreased mobility and long-term osteoarthritis. Also, procedures such as the Brostrom, commonly used for repair in adults, proves to be challenging in the pediatric population as the ligaments are very poorly developed and difficult to suture. Results from this small patient population study reveal that a lateral malleolar periosteal flap utilized for reconstruction of the anterior talofibular ligament yields good radiographic and clinical results. Though the results are encouraging, further evaluation utilizing a larger patient population with prospective data collection and long-term follow-up are needed.            

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