SLR - November 2015 - Michael A. Howell

Anatomic Reconstruction With a Semitendinosus Allograft for Chronic Lateral Ankle Instability

Reference: Dierckman BD, Ferkel RD. Anatomic Reconstruction With a Semitendinosus Allograft for Chronic Lateral Ankle Instability. Am J Sports Med. 2015 Aug;43(8):1941-50.

Scientific Literature Review

Reviewed By: Michael A. Howell, DPM
Residency Program: West Penn Hospital, Pittsburgh, PA

Podiatric Relevance:  Chronic lateral ankle instability (CLAI) is a common pathology treated by podiatrists across the country. Although the modified Brostrom procedure is commonly utilized during surgical correction, certain patient populations are still refractory to this method. Therefore, the authors of this article were interested in studying the effects and benefits of utilization of semitendinosus allograft in adjunct to the modified Brostrom repair.

Methods: This study was a retrospective review of 31 patients (33 ankles) at final follow up (mean 38 months). Between the years 2003-2011, a single surgeon performed anatomic lateral ankle ligament reconstruction with semitendinosus allograft combined with a modified Brostrom procedure for the treatment of CLAI. The decision whether to use semitendinosus allograft or not was based on several criteria designed by the authors as detailed in their paper. Pre-operatively, the following were documented: clinical exam, stress radiographs via Telos machine, VAS score, Tegner score, and AHS score. Intra-operatively, arthroscopy was performed first, addressing any ankle pathology. A semitendinosus graft was then chosen, at a minimum of 14 cm in length. One end was secured to the talus with a biotenodesis scew, then routed through the fibula, and finally anchored to the calcaneus with a second biotenodesis screw. The modified Brostrom was performed over this. Post-operatively, the same parameters were evaluated as the pre-operative evaluation.

Results: Significant improvements were seen in both VAS and AHS scores (85 percent good/excellent results for AHS scale). Based on the Tegner scoring system, 58 percent returned to previous activity level. Radiographically, post-operative talar tilt had decreased significantly. Ten patients who had underwent previous surgery for the same problem did better than those for which this was a primary surgery.  Patients with workers’ compensation involvement experienced significantly lower improvements in their AHS scores. No correlations were found between age, BMI, amount of generalized ligamentous laxity, preoperative/postoperative Tegner score, preoperative/postoperative talar tilt, or postoperative instability and improvements in AHS.

Conclusions: The authors of this study feel that, overall, their results show the use of semitendinosus allograft for the treatment of CLAI can provide high patient satisfaction, decreased pain, a stable ankle with minimal degenerative changes, and improved function. Perhaps most importantly, they note that allograft augmentation can be especially helpful in assisting with revisional repairs. On the same note, they do comment that the vast majority of times, a Brostrom repair itself is often sufficient without need for allograft augmentation. As with any study, there are some limitations including its retrospective nature, small patient population, and more importantly, the fact that there is no control group. However, overall it did show some promising results with use of semitendinosus allograft for CLAI. One important key seems to be patient selection. It does not seem prudent or necessary to have all patients with CLAI undergoing repair with allograft. However, this may be of great supplemental help in the setting of revisional surgeries. Overall, this article may be a good pilot study for a future randomized, prospective trial of the same nature.

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