Hi nemo717-ga, and thanks for your question.
Having recently badly sprained my own ankle, I feel your pain, so to
speak. First, let me say that the following is no substitution for
medical advice or direct evaluation by a physician.
Complete rupture of both the peroneus longus and peroneus brevis
tendons is rare and likely resulted from a significant mechanism of
injury. This would be categorized as a Grade III sprain - the most
severe type. As you've learned, these types of injuries often require
surgical intervention for stabilization of the lateral ankle, as well
as casting or bracing initially.
First, let me give you a little more background:
There are several common surgical procedures that can be performed
when these tendons are completely disrupted. The specific surgery
performed depends on the details of the injury, the anatomy, surgeon
preference and experience, and characteristics of the patient (e.g.
elite athlete, child, elderly, etc.). From what you describe, it is
likely that your surgeon performed either the Watson-Jones or Evans
procedure, detaching the remainder of the peroneus tendon and suturing
(attaching) it to the body of the peroneus longus muscle.
A picture of the anatomy would probably be helpful at this point. You
can find a very good labeled diagram from Bartleby.com:
http://www.bartleby.com/107/Images/large/image441.gif
As you can see, the peroneus longus and brevis run together around the
outside of the ankle and are often injured at the same time. As an
aside, you can also see that they both attach to the lateral portion
of the 5th metatarsal in the mid-foot - one reason that this bone is
sometimes fractured in severe ankle sprains.
You can find a succinct description of the various surgeries employed
after disruption of the peroneus longus and brevis tendons here Curtin
University of Technology in Australia:
http://www.podiatry.curtin.edu.au/encyclopedia/ankle/
The four primary surgeries are Watson-Jones, Evans, Nilsonne, and Lee.
The details can be found at the site above.
The Watson-Jones and Evans procedures don't recreate the normal
anatomy of the ankle, but are thought by some to increase the
stability of the ankle over the other procedures. This may be why
your physician elected to go in this type of direction. If your ankle
had a severe degree of instability, he/she may have thought it better
to increase the stability rather than strictly recreate the anatomic
relationships of an uninjured ankle. In other words, recreating the
normal anatomy may actually cause a decrease in stability over what
you have now, depending on your precise injury and exactly what type
of procedure your physician performed. The correct choice of
procedure would also depend, as I mentioned above, upon your activity
level, age, etc., as well as the amount of scar tissue that may have
formed due to both the injury itself and the surgery. There are
numerous other procedures available to you at this point, including
harvesting other tendons for reconstruction of the peroneus tendons or
cadaveric repair, as you mention in your question.
As one eMedicine article states,
"Surgical therapy: According to a 1999 review by Safran, Zachazewski,
and Benedetti, more than 20 different delayed surgical procedures are
available for chronic ankle instability and sprains. Most of these
procedures are reconstructive in nature and frequently involve
tenodesis between the lateral malleolus and calcaneus, talar head,
and/or the fifth metatarsal. All of these procedures use the peroneus
brevis and/or longus, Achilles tendon, or fascia lata [a covering on a
muscle in the thigh]. None really restore true anatomy."
http://www.emedicine.com/orthoped/topic279.htm
More details can be found in this review article by Drs. Baumhauer and O'Brien:
"Anatomic repair of the lateral-ligament complex supplemented with the
Gould modification has become the preferred method of surgical
treatment, with an 85% to 95% success rate. This approach provides
increased stability through the reinforcement of local host tissue;
preserves subtalar and talocrural motion; has fewer associated nerve
injuries and less morbidity associated with the harvest of tendon
grafts; and provides a quicker functional recovery.
Ankle-reconstruction procedures that sacrifice tendons to be used as
donor tissues are thought to provide a theoretically stronger
construct and, hence, more stability. This increased stability can
result in loss of talocrural and subtalar range of motion and lead to
prolonged recovery and decreased sports performance."
The free full text article is available here:
http://www.nata.org/jat/readers/archives/37.4/attr37-04/pdf/attr_37_04_0458.pdf
Baumhauer JF, O'Brien T. Surgical Considerations in the Treatment of
Ankle Instability. Journal of Athletic Training 2002;37(4):458?462.
All that being said, it is particularly important that you be
evaluated by a competent orthopedic surgeon before embarking on any
re-operation for either reconstructive, reparative, or other
procedure. In that vein, I will turn to recommendations for surgeons.
You do not state whether or not you have a geographical preference,
so I will stick to those orthopedic surgeons across the US who may
best be able to help you.
___________________________________
Although there are limitations in their rankings (primarily due to the
inclusion of some subjective factors such as reputation), US News and
World Report ranks several departments within hospitals around the
country every year, including orthopedic programs. Their ranking
system includes such factors as facilities, staff expertise,
reputation, number of cases, etc. Any program on this listing is a
top rated department and this may help you initially to find a
physician located geographically near you. This may be important for
post-surgical follow-up, etc.
You can find their rankings for orthopedic surgery programs here:
http://www.usnews.com/usnews/health/best-hospitals/rankings/specihqorth.htm
Any of the programs on this list would be a very good start. I have
also researched additional specific physicians who specialize in foot
and ankle surgery with some geographic spread so that you have some
choices for consultation. These physicians are among the top in the
area of foot and ankle surgery, often serving on editorial boards of
major journals and holding academic appointments in recognition of
their accomplishments and abilities. Contact information for each
physician may be found at the link that follows each.
________________
One of the top-rated programs for orthopedic surgery is the
Massachusetts General Hospital at Harvard Medical School. Their
department has an ankle injury program, which you can find here:
http://www.massgeneral.org/ortho/FootAnkle.html
This program is run by the following three physicians:
James Donald Heckman, MD
http://www.massgeneral.org/doctor/Medical_Professional_Detail.asp?MPR=19213&ON=16219
Richard J. deAsla, MD
http://www.massgeneral.org/doctor/Medical_Professional_Detail.asp?MPR=24363&ON=25025
George Harry Theodore, MD
http://www.massgeneral.org/doctor/Medical_Professional_Detail.asp?MPR=11278&ON=22186
Contact information for these three physicians is available at the
links above. All are listed as accepting new patients.
Another possibility in the Boston area is Dr. Michael Wilson at the
Faulkner Hospital / Brigham & Women's Hospital. He also specializes
in foot and ankle surgery and actively participates in academic
medicine. Here is his contact and bio information:
http://www.brighamandwomens.org/mdSearch/MedicalProfessionalDetail.asp?MPR=5152&N=Michael%20G.%20Wilson,%20M.D.&D=Orthopedics&CI=ankle%20surgery,%20foot%20surgery&OP=5200&NP=Yes&L=No%20Data%20Available&PT=Specialist
_______________
Dr. Jeffrey E. Johnson, M.D., at Washington University in St. Louis,
is another accomplished specialist in the area of ankle
reconstruction. You can find his contact and biographical information
here:
http://wuphysicians.wustl.edu/physician2.asp?PhysNum=1029&deptID=7&divisionID=0
_______________
Dr. Judith Baumhauer at the University of Rochester, a co-author of an
article I cited above, is a well known specialist in ankle surgery.
She also serves on the Editorial Board of Techniques in Foot and Ankle
Surgery. She is the Director of the University of Rochester Foot and
Ankle Surgery program. You can find her contact information and
biographical information here:
http://www.urmc.rochester.edu/ortho/faculty/baumhauer.html
_______________
In North Carolina, the Miller Orthopedic practice has been around for
over 75 years and has several well known orthopedic surgeons who
specialize in foot and ankle reconstructions, with some focus on
athletes. Several of their surgeons are senior editors of major
journals in the area of foot and ankle surgery. Their two most
experienced surgeons are:
Dr. W. Hodges Davis
http://www.millerclinic.com/our_physicians/wdavis/
Dr. Robert B. Anderson
http://www.millerclinic.com/our_physicians/randerson/
Miller Othopaedic Clinic recently merged with Charlotte Orthopedic
Specialists, but the above contact information should remain valid.
Here's a link to the merger site:
http://www.millerclinic.com/
Here's a link to the original Miller Orthopedic site, with further
contact information:
http://www.millerclinic.com/index.asp
_______________
At the Ohio State University Dept. of Orthopedic Surgery, Dr. Berlet
is well known and specializes in foot and ankle surgery.
http://www.ortho.ohio-state.edu/Faculty/berlet.htm
_______________
At Duke, Dr. Mark Easley specializes in Foot, Ankle, and Knee surgery.
http://www.dukehealth.org/physicians/4B3CCE08F302361C85256DFD006A91D0
_______________
Todd Kile, MD, Mayo Clinic, Scottsdale, Arizona. Subspecializes in
trauma reconstruction.
http://www.mayoclinic.org/orthopedicsurgery-sct/10650920.html
_______________
Dr. William McGarvey at the University of Texas is an Associate
Professor and ankle/foot specialist.
http://www.uth.tmc.edu/ortho/people/wmcgarvey.html
_______________
Dr. Charles Saltzman, University of Iowa
http://www.uihealthcare.com/depts/med/orthopaedicsurgery/faculty/saltzman.html
_______________
Dr. Brian G. Conley, Cleveland Clinic. Associate Editor of Foot and
Ankle International. Specializes in sports injuries of the foot and
ankle.
http://sck.clevelandclinic.org/fhc/staff/physicians.asp?staff=1673029
_______________
Dr. Anthony Watson, Drexel University, West Penn Allegheny Health
System, Pittsburgh, PA.
http://www.wpahs.org/patients/physician/bio.cfm?physician=794
_______________
Dr. Lowell Wiel of the Weil Foot and Ankle Institute, Des Plaines, Illinois
http://www.weil4feet.com/about_team_weilsr.php
_______________
Dr. Richard Ferkel of the Southern California Orthopedic Institute, UCLA
http://www.scoi.com/doctors/rdf.htm
http://www5.aaos.org/courses/ankle/faculty/faculty_ferkel.cfm
_______________
Dr. E. Greer Richardson, Campbell Clinic, Memphis, TN.
Editor-in-Chief of one of the primary journals in the field, Foot &
Ankle International.
http://www.campbellclinic.com/cms.asp?ID1=Physicians&ID2=Bio&ID3=25
http://www.campbellclinic.com/cms.asp?ID1=On%2Dline+Services&ID2=Appointment+Information
___________________
I hope this information is useful and I wish you the best in your
recovery. Please feel free to request clarification or request
additional physicians for a more specific location.
-welte-ga |
