BACKGROUND
The Modified Bröstrom stabilization is an anatomic reconstruction performed for chronic lateral ankle injuries of the anterior talofibular and calcaneofibular ligaments1. At times, tissue viability, injury chronicity, and/or severity may require a non-anatomic repair (e.g., Evans Tenodesis), necessitating a tendon transfer2,3. This creates a need for additional surgery and rehabilitation with all its associated complications4-6. A novel use of a biologic collagen implant (OrthADAPTT Bioimplant, Pegasus Biologics, Irvine, CA) is described, which strengthens the Bröstrom-Gould repair and obviates the need for additional tendon harvesting.
The OrthADAPTT Biologic Collagen Implant (Pegasus Biologics, Irvine, CA) is a biologic scaffold that provides support for augmentation by fortifying and promoting tissue ingrowth to enhance the stability of the reconstruction procedure. The purpose of this poster is to illustrate a new surgical technique using the Pegasus OrthADAPTT Bioimplant for augmentation of the Modified Bröstrom procedure for reconstruction of the lateral ankle ligament complex.
MATERIALS AND METHODS
SURGICAL TECHNIQUE
The procedure is performed in the supine position under IV sedation. An incision is made just below the tip of the distal fibula and extended distally with the skin tension lines anterior and inferior to the fibula. The initial skin incision is deepened, taking care to prevent violation of the subtalar joint, peroneal nerve, artery, and tendons. The ankle joint is identified using a 25-guage needle or via fluoroscopy. The anterior lateral ankle capsule and ATFL are sectioned and reflected proximally. The lateral talar dome may be inspected for the presence of any osteochondral lesions or osteophytes. The foot is held is maximal eversion and the ATF ligament is repaired as a Modified Bröstrom in a pants-over-vest fashion using 2.0 FiberWire® (Image #2).
A 2x15cm sheet of OrthADAPTT Bioimplant is prepared according to the manufacturer directions. A 2x15cm strip is utilized (Image #3) and two hemostats are placed at both ends of the strip and are twisted to make a cable (Image #4). One end of the strip is sutured to the distal end of the ATFL using 2.0 FiberWire®. A hemostat is placed through the repaired ATFL and the OrthADAPTT Bioimplant cable is fed and drawn through (Image #5). This maneuver is repeated 3-4 times over and under in a weave fashion through the repaired ATFL and sutured to the proximal end of the ATFL. Skin closure is obtained using absorbable sutures and adhesive strips.
RESULTS
A 31-year old healthy female presented with a history of chronic right ankle sprains for 10 years. She had been treated with conservative measures and physical therapy, but continued to have recurrent inversion sprains and instability. She had consistent ankle edema due to the sprains, and had difficulty wearing shoe gear appropriate to her line of work. On physical exam, there was increased inversion to the right ankle, and weakness to resisted eversion. There was a positive anterior drawer test and talar tilt, which was evident on fluoroscopic imaging (Image #1).
She underwent a modified Bröstrom procedure utilizing the OrthADAPTT Bioimplant as described. There was no evidence of osteochondral lesions on visual inspection. The patient reported no pain at 3 weeks post-operatively, with minimal swelling consistent with surgery. There was significant restriction of inversion as compared with pre-operative values, with improved strength to resisted inversion ( Image #6) The patient returned to activities of daily living in gym shoes and an ankle brace at 6 weeks, and progressed to normal shoe wear at 2 months without incident. An MRI obtained at 9 months demonstrates structural integrity of the reconstruction and implant (Image #7).
DISCUSSION AND CONCLUSION
The OrthADAPTT Biologic Collagen Implant is a biologic scaffold that provides support for augmentation by fortifying and promoting tissue ingrowth to enhance the stability of the Modified Bröstrom procedure. Additionally, it prevents the need for tendon transfer and its inherent complications. Long term outcome studies are, however, necessary to demonstrate the efficacy of the OrthADAPTT Bioimplant in various reconstructive procedures.
BIBLIOGRAPHY
1. Kuhn MA, Lippert FG. Revision lateral ankle reconstruction. Foot Ankle Int. 2006 Feb;27(2):77-81.
2. Nimon GA, Dobson PJ, Angel KR, Lewis PL, Stevenson TM.A long-term review of a modified Evans procedure. J Bone Joint Surg Br. 2001 Jan;83(1):14-8.
3. Sammarco GJ, Idusuyi OB. Reconstruction of the lateral ankle ligaments using a split peroneus brevis tendon graft. Foot Ankle Int. 1999 Feb;20(2):97-103.
4. Sugimoto K, Takakura Y, Kumai T, Iwai M, Tanaka Y. Reconstruction of the lateral ankle ligaments with bone-patellar tendon graft in patients with chronic ankle instability: a preliminary report. Am J Sports Med. 2002 May-Jun;30(3):340-6.
5. Coughlin MJ, Schenck RC Jr, Grebing BR, Treme G. Comprehensive reconstruction of the lateral ankle for chronic instability using a free gracilis graft. Foot Ankle Int. 2004 Apr;25(4):231-41.
6. Marsh JS, Daigneault JP, Polzhofer GK. Treatment of ankle instability in children and adolescents with a modified Chrisman-Snook repair: a clinical and patient-based outcome study. J Pediatr Orthop. 2006 Jan-Feb;26(1):94-9.
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