Alignment and Instability: Managing Mechanical Contributors to Recurrent Ligament Injury and Instability
Ankle sprains are one of the most common injuries encountered by orthopedic providers, and a large percentage of patients go on to develop recurrent ankle instability. In a subset of patients, mechanical alignment contributes to recurrent instability. In particular, patients with subtle cavovarus alignment are at risk for recurrent sprains and may go underrecognized. Thorough physical examination, including assessment of hindfoot alignment, Coleman block testing, Silfverskiöld testing, and neurologic examination, should be performed in patients with recurrent instability and cavovarus alignment. Imaging studies in the form of weight-bearing ankle radiographs and hindfoot radiographs should be performed; MRI and CT can be considered in indicated cases. Understanding if the deformity is forefoot or hindfoot driven is paramount to appropriate management. Nonoperative treatment in the form of physical therapy, orthotics, and bracing is generally first-line treatment. In patients who fail conservative management, operative treatment in the setting of recurrent ankle instability and cavovarus alignment should address the fixed deformity in the hindfoot and/or forefoot as well as the ligamentous insufficiency. Lateralizing calcaneal osteotomy is indicated to address hindfoot-driven varus, while first-ray dorsiflexion osteotomy is indicated in forefoot-driven varus. Lateral ligament reconstruction can be performed with these procedures, and adjunct procedures to address intra-articular pathology, peroneal tendon pathology, and gastrocnemius contracture should also be considered. When recognized and addressed, patients with cavovarus alignment and recurrent ankle instability can have excellent surgical outcomes and return to a high level of activity.
