Podiatry Arena members do not see these ads

I have a patient who is a chronic lat ankle sprainer (and generally very lax all over). Had surgery 5 yrs ago to remove fractured segment of tallus and now presenting with ankle pain and significant instability. Two opposing opinions now in...first (podiatrist) told her to do tenodesis with peroneus longus....second (ortho surgeon) recommends tenodesis with allograft combined with brostrum (and says you "never" use per. longus). Pt now looking for guidance regarding which route to take...does anyone have an opinion/experience regarding this situation?...

Well, I think we need to know a bit more about the original injury, what part of the talus was removed and why.

Prior to deciding on a lateral ankle stabilization procedure you need to determine why it's unstable.
Is it unstable due to a syndesmotic injury or ATF and or CF, Lig. laxity, Pes Cavus with lig. damage, unstable mortice, progressive and repetitive ankle sprains, etc.....

As for PB vs PL; the brevis is normally sacrified when a procedure using tendon is selected.
The use of allografts and or PB rerouting is made by the surgeon depending and his criteria for procedure selection.

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

All good points!!....Thank you for the reply-

I have not seen a surgical report, although I know that the reason for the original surgery was a severe inversion injury that caused the fracture and that her scar is on the medial ankle just distal to the malleolus (if either of those facts help in determining what part of tallus was removed....)

She is definately generally lax (has all positive Brighton criteria, loss of MLA upon standing, and chronic history of repetitive lateral ankle sprains on the left- involved ankle). I believe, as do both doctors who have provided diagnosis/recommendations, that the instability is a result of ligamentous laxity (her anterior drawer test is VERY lax- the most that I have ever seen).

I hope this info helps in generating a more specific idea of best option...some research I have found shows that for those with generalized laxity the best outcome is from a combo of Brostrom and tenodesis. She is returning to see me in 2 days, so I'd like to have some helpful recommendations/info for her...any opinions/experience is greatly appreciated!

Hi again:

She may have had an osteochondral fracture or possibly a "chip" fracture of the talar neck, both would allow access through a medial incision although the Osteochondral fracture is normally repaired athroscopically ( especially only five years ago). I thought perhaps a posterior process Fx but this would be removed through a posterior incision.

I'm trying to read between the lines....you have not mentioned any Hx of sprains or problems with the contralateral ankle which might help to discount general lig. laxity as an underlying etiology for her instability.

I'm a bit confused as to your role in her care. If you are not going to actually perform the surgery then the choice of procedures is not yours to make. If you are trying assist her in making a decision as to which surgeon to go to to have the procedure I would look more into the success rate and experience of the surgeons in question. If you are trying to help her "stay out of the Operating room" with an orthotic or other supportive measures then try this first prior to suggesting she follow through with surgery.

The selection of a procedure, especially when multiple factors are involved, is a very large part of being a successful surgeon. It really is not your responsibility, as a "referring" physician, to suggest a particular procedure.

I hope that helps.

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

Steve, thank you again for your reply. I should have clarified this from the beginning...I am this pt's physical therapist (this is in my profile...gee, I guess everyone isn't reading that!...wink)- and I am certainly not in any way trying to reommend a certain procedure to her (that's what you wonderful Dr's are for:)- like I said, she has gotten conflicting opionions regarding surgery, and since I spend about 2-3 hours a week with her we have lots of time to discuss these things...so, I am just trying to seek information from those wiser than myself that I can use for patient education and advocacy in an attempt to assist her in making this tough decision with her docs!:) I certainly appreciate all of your help!

Katie

Katie - I agree with Steve. Let me just add that t he majority of ankle stabilization procedures that I have preformed over the last 19 years have been Brostrums. That said, The fact that she has a strong PMH of ligamentous laxity and a past surgical history in the ankle, I would recommend a reconstructive procedure in addition to tighetening the ATFL. Every surgeon has their preference for which procedure works best. Mine is to take a 15 cm split piece of the PL tendon and through a drill hole in the fibula, recreate and/or re-inforce the ATF/CF ligaments. I have never found the need to completely sacrifice the PB or PL and with proper rehab and po bracing, the repair is profoundly stable and reliable. No bridges are burned (tendons sacrificed) and patients are very happy. Again, every surgeon has their prefered procedure and rational. No you have mine. Best of Luck!

S. Jeffrey Siegel, DPM, FACFAS