SLR - July 2015 - Douglas L. Croff

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

Reference:  Mathieu P, Marcheix P, 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.  Journal of Pediatric Othopaedics. 2015 Jul-Aug; 35(5):511-515.

Scientific Literature Review

Reviewed By: Douglas L. Croff, DPM
Residency Program: Detroit Medical Center

Podiatric Relevance:  Lateral ligament instability is a common problem and is increasing in the pediatric population.  This is suggested to be due to higher level of participation in sporting events and practices at younger ages.  Greater thought is given to the pediatric population to keep tendons intact; to prevent imbalance, further development of arthritis, and preserve the tendons as possible future surgical options if necessary as an adult.  The use of a fibular periosteal flap to reconstruct the lateral ligament does not sacrifice tendons and has successful outcomes.

Methods:  This study was a retrospective analysis of lateral ligament reconstruction in 14 children with a mean age of 12.7 years.  Functional assessment was determined by AOFAS and Gould’s criteria.  Radiologic assessment included tibiotalar tilt and anterior translation of the talus.   A periosteal flap was harvested from the fibula and routed through the neck of the talus using a 3.5mm drill and sutured on to itself to reconstruct the anterior talofibular ligament.  Patients were non-weightbearing for 6 weeks followed by 2 months of physical therapy.

Results:  The mean follow up was 3.1 years with no patients lost to follow up.  Prior to surgery the mean number of sprains was 6 per patient over a minimum of 6 months leading to cessation of sporting activity.  AOFAS scores increased from 61 pre-op to 95 post-op.  Gould’s classification indicated 11 excellent, 2 good, 1 average and no bad results.  Tibiotalar tilt decreased from 14deg to 4deg, and anterior translation of the talus went from 11mm to 2mm.  Complications included 3 superficial necroses and 3 paresthesia which resolved uneventfully.
Conclusions:  Chronic ankle instability, although rare in pediatric patients, is increasing likely due to higher levels of participation in sports at younger ages.  The diagnosis needs to be made and treatment performed before further progression of the disorder occurs.   Repair using a periosteal flap produces good clinical and radiographic results sparing any need to harvest tendons in a young patient.  As stated by the authors, further study is needed in a larger cohort to determine efficacy although the early results seen in this study show good patient outcomes.

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