- THIS MATERIAL IS PUBLISHED AND PROTECTED BY U.S. COPYRIGHT LAW - REPRODUCTION PROHIBITED UNLESS FOR PERSONAL USE, EXCEPTING AUTHOR PERMISSION - MEDIAL ANKLE STABILIZATION UTILIZING TIBIALIS POSTERIOR TENDON GRAFT Peter F. Kelly, D.P.M., F.A.C.F.A.S. Diplomate, American Board of Podiatric Surgery Fellow, American College of Foot and Ankle Surgeons ABSTRACT Presented is a method for surgically strengthening a severely weakened or extensively ruptured deltoid ligament. The Posterior Tibial tendon used as an autogenous graft serves as an adequate strengthening measure. MEDIAL ANKLE STABILIZATION UTILIZING TIBIALIS POSTERIOR TENDON GRAFT Few procedures about medial ankle stabilization are found in the literature. Those that are written are adequate only for minor deltoid ruptures. Upon discovering that extensive surgical reconstruction was necessary, an innovative technique using autogenous grafting with atraumatic graft explantation was found to provide the optimal solution. Injury to ligaments of the ankle is a problem frequently encountered by the Podiatric foot specialist and surgeon. These sprain injuries vary from overstressed, intact ligaments (grade I), to complete rupture (grade III). They may also present with an accompanied avulsion of their corresponding osseous attachments. Many procedures have been written to describe repair of ligaments of the lateral ankle. These comprise approximately 85% of all ankle sprains. Soft tissue injuries of the deltoid ligament are encountered only 15% of the time. An extensive literature search will produce few references for deltoid repair.(1) Injuries to the deltoid ligament are far more serious because of the possibility of injury to the interosseous membrane, the medial or posterior aspect of the tibia, or a high fibular fracture which may be missed on routine X-ray studies. Knee X-rays, stress exams including the anterior drawer test, and ankle arthrograms taken as soon as possible after the injury will help to rule out these complications. It is important in determining the history of the injury to have the patient recall the direction of movement of the foot and ankle. They may also describe feeling or hearing a "pop", and complain of their ankles being weak or that they have a tendency to fall. Treatment of acute sprains includes immediate icing of the area after the injury followed by compressive dressings to reduce edema and elevation. Decisive action must be taken early in the course of therapy to decide either surgical or conservative treatment. Nonsurgcial treatment includes a below-the-knee cast, soft cast or ankle brace for a minimum of three to six weeks depending on severity of the injury, restricted ambulation, oral antiinflammatory medications, with the physical therapy modalities of ultrasound or hydrotherapy. Surgical repair of the deltoid ligament repair has been described by Schoolfield (1952) and involves reattachment of the deltoid ligament just above its natural origin. The DuVries procedure (1965) involves a cross-hatched plication of the deltoid ligament in a vertical cross fashion. Although these procedures increase the stability of the medial ankle, the primary repair of the deltoid ligament depends upon adequate repair substance initially (2). The authors found that it was necessary to create an alternative procedure utilizing the strength of a tendenous graft to produce a repair which provides adequate strength and which is anticipated to provide adequate stability. CASE PRESENTATION A 23 year old woman presented with the chief complaint of diffuse pain on the outside of her left ankle and a tendency of weakness and instability of causing her to lose balance and fall. She related a history of acute trauma to the area. While working at a warehouse a forklift vehicle ran over her left foot causing her to twist her leg inward with her foot anchored to the ground. Examination revealed excessive frontal plane motion of the ankle when mildly stressed along with pain and swelling over the ankle. X- rays revealed hypertrophic growth of the distal tibia and an old fracture which produced a free floating fragment in the area. Osseous impingement of the subtalar joint inversion was present produced compensatory stress and pain on surrounding ankle ligaments. Further tests revealed no other complications. DESCRIPTION OF OPERATION The patient was placed on the Operating Room table in the supine position with a pneumatic tourniquet was placed around the left lower leg. The left foot and ankle were prepped in the usual sterile manner. The left lower extremity was then elevated for three minutes and the ankle tourniquet inflated to 250 mm. Hg. Upon induction of intravenous sedation the left medial ankle was locally anesthetized using a 1:1 ratio of 2% Xylocaine plain and 0.5% Marcaine plain. A 10 cm. hockeystick incision was placed parallel to, and two cm. anterior to, the midline of the tibia, curving anteriorly for its distal 3.5 cm. All vital neurovascular structures were retracted anteriorly. Upon encountering of the tibial periosteum, a centered 3.0 cm incision was made parallel to and continuing distally off of the tibia. The osseous extension of the tibia was palpated with a periosteal elevator whereupon a pseudarthritic attachment between the fragment and the tibia was identified. Utilizing a power oscillating saw, the distal hypertrophied portion of the tibia was then excised including the fragment (see fig. 2). All distal margins of the tibia were then smoothed to a normal anatomical contour. The foot was then inverted and normal subtalar inversion inversion demonstrated. The posterior, anterior and inferior portions of the deltoid ligament were noted to be fragmented and completely torn from their site of insertion. Examination revealed a lack of ligamentous material for adequate primary repair. An autogenous graft procedure was necessitated. A 6.0 cm incision was performed over the sheath of the posterior tibial tendon and delicately dissected off of the tendon, the sheath being retracted anteriorly and posteriorly. Two convergent parallel incisions were made centrally along a 4.0 cm. length of the tendon. This provided a graft measuring approximately 4.0 cm x 0.5 cm. The anterior and posterior portions of the posterior tibial tendon were then reapproximated using simple interrupted 3-0 Dexon suture. A centralized extraction of the graft of the tendon was utilized to minimize trauma to the tendon while maintaining all of its original strength. The resected portion of tendon was then placed in saline solution. Partial repair of the deltoid ligament was accomplished using primary closure reenforced with periosteal tissues of the tibia, using simple interrupted sutures of 3-0 Dexon (see fig. 3). With the foot was held in neutral position, the tendonous graft was positioned over the site of the deltoid ligament. In a dorsal-posterior to plantar-anterior direction, the graft was sutured to the deep parts of the deltoid's natural origin. It was also sutured to the deltoid ligament distally and proximally through the most superficial aspects of the bone itself. All of these sutures were performed with 3-0 Dexon (see fig. 4). As the tendonous graft was applied, it was also thinned to approximate the normal anatomical configuration and orientation of the deltoid ligament. The deep fascia was then closed over the medial ankle area using 3-0 Dexon and the superficial fascia reapproximated with 4-0 Dexon. Skin margins were reapproximated with a running subcuticular suture of 5-0 Vicryl. The surgical site was washed with sterile saline. Saline irrigation was performed periodically during the procedure to maintain tissue viability. Approximately 0.5 cc. of Hexadrol was then infiltrated to soft tissues proximal and peripheral to the surgical site. The site was covered with a sterile dressing consisting of saline moistened Owen's silk, 4 x 4's, neurological fluff, Kerlix, and Kling. The patient tollerated the procedure and anesthesia well. Vascular status returned to normal preoperative levels following release of the ankle tourniquet, and the patient was brought to the Recovery Room with vital signs stable and in apparent satisfactory condition. A below- the-knee cast was applied. Patient was advised to use crutches non- weightbearing, and to limit general activity. The patient was seen at the office at one to two week intervals. The below-the-knee cast was changed at two weeks post-op and a new dry sterile dressing ws applied. Examination revealed uneventful healing. Three weeks later the patient was seen again. Having had no complaints, anterior-posterior ankle X-rays were taken through the cast which confirmed uneventful healing. One week later the below-the-knee cast was removed and debridement of the surgical eschar revealed minimal and expected inflammation. An ankle brace and surgical shoe was dispensed. Ambulation was advised. Patient stated she was doing fine. She was instructed continue only limit activity. The surgical shoe was worn for three weeks and healing continued unremarkably. Due to the necessity of extensive ambulation in her employment, she was returned to work twelve weeks after surgery. SUMMARY A procedure for reconstructing the deltoid ligament has been described. This provides more strength than direct primary repair described in the literature. It is hoped that the deltoid reconstruction procedure described will be helpful for the Podiatric practitioner and surgeon to add to an armementarium of dealing with medial ankle injuries. REFERENCES 1. Cox, Jay S., Surgical and Nonsurgical Treatment of Acute Ankle Sprains. Clinical Orthopedics and Related Research, No. 198; Sept. 1985; Pgs. 118-26. 2. Mann, Roger A., DuVries' Surgery of the Foot. Chapter on "Major Surgical Procedures for Disorders of the Ankle, Tarsus and Midtarsus", Pgs. 537-39. The C. V. Mosby Company, Saint Louis, MO, 1978.