Operative Orthopädie und Traumatologie

, Volume 31, Issue 3, pp 169–179 | Cite as

Lateral collateral ligament repair

Anatomical ligament reinsertion with augmentation using inferior extensor retinaculum flaps
  • Yves TournéEmail author
  • Marco Peruzzi
Surgical Techniques



For chronic lateral ankle instability an anatomical repair procedure of the lateral collateral ligaments (LCL) of the ankle with augmentation by an inferior extensor retinaculum (IER) flap is proposed.


To treat the mechanical parts of an instable ankle involving both LCL and subtalar joint ligament damage.


This technique is not suitable when the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) are in a poor anatomical condition (exhaustive preoperative lesion mapping mandatory).

Surgical technique

This technique combines the reinsertion of the remnants of the lateral ligaments of the ankle, the ATFL and the CFL using anchors, with augmentation using an inferior extensor retinaculum flap fixed in a tunnel by an interference screw. This flap works as an actual neoligament, providing not only reinforcement and collagen input but also peripheral stabilization of the subtalar joint by its calcaneal insertion and reinforcing the CFL stabilizing effect.

Postoperative management

Following immediate immobilization in an ankle-foot orthosis, proprioceptive physiotherapy exercises are initiated with a return to sports depending on the type of sport.


The postoperative outcomes and long-term follow-up results of this technique are discussed.


Ankle instability Lateral collateral ligament laxity Ligament reconstruction Extensor retinaculum flap Subtalar joint 

Rekonstruktion des lateralen Kollateralbandapparats am oberen Sprunggelenk

Anatomische Reinsertion des Ligaments durch Augmentation mittels Retinaculum-extensorum-inferius-Flap



In diesem Beitrag wird ein Verfahren zur anatomischen Rekonstruktion des lateralen Kollateralbandapparats („lateral collateral ligaments“, LCL) des Sprunggelenks mittels Augmentation unter Verwendung eines Retinaculum-extensorum-inferius(IER)-Flaps zur Behandlung einer chronischen lateralen Sprunggelenkinstabilität vorgeschlagen.


Indikation ist die Behandlung eines mechanisch instabilen Sprunggelenks mit Beteiligung sowohl des LCL als auch einer Bandverletzung des Subtalargelenks.


Diese Technik ist nicht geeignet, wenn sich das Lig. talofibulare anterius (ATFL) sowie das Lig. calcaneofibulare (CFL) massiv substanzgemindert sind (ein Mapping ist präoperativ unbedingt erforderlich).


Diese Technik kombiniert die Reinsertion der Residuen der Kollateralbänder des Sprunggelenks, des ATFL und des CFL mittels Ankern durch Augmentation unter Verwendung eines Retinaculum-extensorum-inferius-Flaps, der in einem Tunnel mittels einer Interferenzschraube fixiert wird. Dieser Retinakulumstreifen fungiert als eigentliches Neoligament, welches nicht nur eine substantielle Verstärkung bietet, sondern auch als periphere Stabilisierung des Subtalargelenks dient.


Nach unmittelbar postoperativer Immobilisation in einer Sprunggelenk-Fuß-Orthese wird mit propriozeptiven physiotherapeutischen Übungen begonnen. Die Rückkehr zum Sport hängt von der Sportart ab.


Die postoperativen und die Langzeit-Follow-up-Ergebnisse dieser Technik werden diskutiert.


Instabilität des Sprunggelenks Laxität des inneren und äußeren Seitenbands Bandrekonstruktion Retinaculum-extensorum-Flap Subtalargelenk 


Compliance with ethical guidelines

Conflict of interest

Y. Tourné is consultant for Arthrex, Stryker and In2Bones. M. Peruzzi declares that he has no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case. Additional written informed consent was obtained from the patient or the legal representative for whom identifying information is included in this article.

Supplementary material

Video: Anatomic lateral ligament ankle repair using ERF. Courtesy of Arthrex GmbH, München


  1. 1.
    Blanchet A (1975) La réfection capsuloligamentaire dans les instabilités chroniques de la tibiotarsienne. Rev Chir Orthop 61(suppl II):175–176PubMedGoogle Scholar
  2. 2.
    Bonnel F, Toullec E, Mabit C, Tourné Y (2010) Chronic ankle instability: biomechanics and pathomechanics of ligaments injury and associated lesions. Orthop Traumatol Surg Res 96:424–432CrossRefGoogle Scholar
  3. 3.
    Brostrom L (1966) Sprained ankles. V . Treatment and prognosis in recent ligament ruptures. Acta Chir Scand 132:537–550PubMedGoogle Scholar
  4. 4.
    Dalmau-Pastor M, Yasui Y, Calder JD, Karlsson J, Kerkhoffs GM, Kennedy JG (2016) Anatomy of the inferior extensor retinaculum and its role in lateral ankle ligament reconstruction: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 24(4):957–962CrossRefGoogle Scholar
  5. 5.
    Dalmau-Pastor M, Malagelada F, Kerkhoffs GMMJ, Manzanares MC, Vega J (2018) X‑shaped inferior extensor retinaculum and its doubtful use in the Bröstrom-Gould procedure. Knee Surg Sports Traumatol Arthrosc 26(7):2171–2176CrossRefGoogle Scholar
  6. 6.
    Donovan L, Hart JM, Hertel J (2014) Lower-extremity electromyography measures during walking with ankle-destabilization devices. J Sport Rehabil 23(2):134–144CrossRefGoogle Scholar
  7. 7.
    Duquennoy A, Letendard J, Loock P (1980) Remise en tension ligamentaire externe dans les instabilite ́s chroniques de la cheville. A’ propos de 22 cas. Rev Chir Orthop 66:311–316PubMedGoogle Scholar
  8. 8.
    Gould N, Seligson D, Gassman J (1980) Early and late repair of the lateral ligament of the ankle. Foot Ankle 1:354–358Google Scholar
  9. 9.
    Guillo S, Bauer T, Lee JW, Takao M, Kong SW, Stone JW, Mangone PG, Molloy A, Perera A, Pearce CJ, Michels F, Tourné Y, Ghorbani A, Calder J (2013) Consensus in chronic ankle instability: Aetiology, assessment, surgical indications and place for arthroscopy. Orthop Traumatol Surg Res 99:S411–S419CrossRefGoogle Scholar
  10. 10.
    Krips R, Brandsson S, Swensson C (2002) Anatomical reconstruction and Evans tenodesis of the lateral ligaments of the ankle: clinical and radiological findings after follow up for 15 to 30 years. J Bone Joint Surg Am 84:232–236CrossRefGoogle Scholar
  11. 11.
    Krips R, Van Dijk CN, Halasi PT (2001) Long-term outcome of anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a multicenter study. Foot Ankle Int 22(5):415–421CrossRefGoogle Scholar
  12. 12.
    Mabit C, Chaudruc JM, Fiorenza F (1998) Lateral ligament reconstruction of the ankle: comparative study of peroneus brevis tenodesis versus periostal ligamentoplasty. Foot Ankle Surg 4:71–76CrossRefGoogle Scholar
  13. 13.
    Mabit C, Tourné Y, Besse J‑L et al (2010) Chronic lateral ankle insta-bility surgical repairs: the long-term prospective. Orthop Traumatol Surg Res 96:417–423CrossRefGoogle Scholar
  14. 14.
    Matsui K, Oliva XM, Takao M, Pereira BS, Gomes TM, Lozano JM, Glazebrook M, ESSKA AFAS Ankle Instability Group (2017) Bony landmarks available for minimally invasive lateral ankle stabilization surgery: a cadaveric anatomical study. Knee Surg Sports Traumatol Arthrosc 25(6):1916–1924CrossRefGoogle Scholar
  15. 15.
    Muijs SP, Dijkstra PD, Bos CF (2008) Clinical outcome after anatomical reconstruction of the lateral ankle ligaments using the Duquennoy technique in chronic lateral instability of the ankle: a long-term follow-up study. J Bone Joint Surg 90(1):50–56CrossRefGoogle Scholar
  16. 16.
    Néri T, Barthélémy R, Tourné Y (2017) Radiologic analysis of hindfoot alignment: comparison of Méary, long axial, and hindfoot alignment views. Orthop Traumatol Surg Res 103(8):1211–1216CrossRefGoogle Scholar
  17. 17.
    Pearce CJ, Tourné Y, Zellers J, Terrier R, Toschi P, Silbernagel KG, ESKKA-AFAS Ankle Instability Group (2016) Rehabilitation after anatomical ankle ligament repair or reconstruction. Knee Surg Sports Traumatol Arthrosc 24(4):1130–1139CrossRefGoogle Scholar
  18. 18.
    Saragaglia D, Fontanel F, Montbarbon E et al (1997) Reconstruction for the lateral ankle ligaments using an inferior extensor retinaculum flap. Foot Ankle Int 18:723–725CrossRefGoogle Scholar
  19. 19.
    Schepers T, Vogels LMM, van Lieshout EMM (2011) Hemi-Castaing ligamentoplasty for the treatment of chronic lateral ankle instability: a retrospective assessment and outcome. Int Orthop 35:1805–1812CrossRefGoogle Scholar
  20. 20.
    Terrier R, Rose-Dulcina K, Toschi B, Forestier N (2014) Impaired control of weight bearing ankle inversion in subjects with chronic ankle instability. Clin Biomech 29(4):439–443CrossRefGoogle Scholar
  21. 21.
    Tourné Y, Besse JL, Mabit C (2010) Chronic ankle instability. Which tests to assess the lesions? Which therapeutic options? Orthop Traumatol Surg Res 96:433–446CrossRefGoogle Scholar
  22. 22.
    Tourné Y, Mabit C, Moroney P et al (2012) Long-term follow-up of lateral reconstruction with extensor retinaculum flap for chronic ankle instability. Foot Ankle Int 33(12):1079–1086CrossRefGoogle Scholar
  23. 23.
    Tourné Y (2015) Arthroscopie de la cheville et instabilité : mise au point. In: La cheville instable. Elsevier, Masson, pp 133–135Google Scholar
  24. 24.
    Tourné Y, Mabit C (2017) Lateral ligament reconstruction procedures for the ankle. Orthop Traumatol Surg Res 103(1):S171–S181CrossRefGoogle Scholar
  25. 25.
    Trichine F, Friha T, Boukabou A, Belaid L, Bouzidi T, Bouzitouna M (2018) Surgical treatment of chronic lateral ankle instability using an inferior extensor retinaculum flap: a retrospective study. J Foot Ankle Surg 57(2):226–231CrossRefGoogle Scholar
  26. 26.
    Van der Rijt A, Evans GA (1984) The long term results of Watson Jones tenodesis. J Bone Joint Surg Br 66:371–375CrossRefGoogle Scholar
  27. 27.
    Van Dijk CN, Tol JL, Verheyen CC (1997) A prospective study of prognostic factors concerning the outcome of arthroscopic surgery for anterior ankle impingement. Am J Sports Med 25:737–745CrossRefGoogle Scholar

Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2019

Authors and Affiliations

  1. 1.Foot and Ankle Institute of GrenobleCentre Ostéo Articulaire des CèdresEchirollesFrance
  2. 2.Largo Agostino Gemelli, Facoltà di Medicina e Chirurgia, Istituto di Ortopedia e TraumatologiaUniversità cattolica del Sacro CuoreRomaItaly

Personalised recommendations