Postoperative Imaging of the Ankle: Ligament and Tendon Reconstruction

Abstract

Tendon and ligament disorders are common indications for ankle surgery. Numerous surgeries and related modifications, ranging from simple repairs and debridement to complex reconstructions with tendon transfers or graft, are available. Knowledge of postoperative imaging appearances of common ankle surgeries is critical to identify complications and aid assessment of clinical treatment failure. This comprehensive review article discusses the surgical indications, techniques, imaging appearances, and complications—specifically those related to minimally invasive or arthroscopic surgery—for various ankle and foot conditions. It includes anatomical (Brostrom type) and nonanatomical lateral ligament repairs for ankle instability. Medial compartment procedures are described, such as peroneal tendon and retinacular repairs, as well as treatments for progressive collapsing flatfoot deformity, formerly known as posterior tibial tendon dysfunction or acquired flatfoot deformity. We also examine posterior compartment procedures, focusing on Achilles tendon repairs. Primary imaging modalities covered are magnetic resonance imaging, ultrasound, computed tomography, and radiographs, including expected postoperative appearances and the usefulness of each modality.

Keywords

ankle ligament repair - Achilles tendon surgery - posterior tibial tendon dysfunction - chronic ankle instability - postoperative imaging

Publikationsverlauf

Artikel online veröffentlicht:
11. Februar 2025

• References

• 1 Myerson MS, Thordarson DB, Johnson JE. et al. Classification and nomenclature: progressive collapsing foot deformity. Foot Ankle Int 2020; 41 (10) 1271-1276
• 2 Chang SH, Morris BL, Saengsin J. et al. Diagnosis and treatment of chronic lateral ankle instability: review of our biomechanical evidence. J Am Acad Orthop Surg 2021; 29 (01) 3-16
• 3 Allen T, Kelly M. Modern open and minimally invasive stabilization of chronic lateral ankle instability. Foot Ankle Clin 2021; 26 (01) 87-101
• 4 Salat P, Le V, Veljkovic A, Cresswell ME. Imaging in foot and ankle instability. Foot Ankle Clin 2018; 23 (04) 499-522.e28
• 5 Brodsky JW, Toppins A. Postsurgical imaging of the peroneal tendons. Semin Musculoskelet Radiol 2012; 16 (03) 233-240
• 6 Li J, Fang M, Van Oevelen A, Peiffer M, Audenaert E, Burssens A. International Weightbearing CT Society. Diagnostic applications and benefits of weightbearing CT in the foot and ankle: a systematic review of clinical studies. Foot Ankle Surg 2024; 30 (01) 7-20
• 7 Adler RS. What is the place of ultrasound in MSK imaging?. Skeletal Radiol 2024; 53 (09) 1699-1709
• 8 Kumar Y, Alian A, Ahlawat S, Wukich DK, Chhabra A. Peroneal tendon pathology: PRE- and post-operative high resolution US and MR imaging. Eur J Radiol 2017; 92: 132-144
• 9 Bianchi S, Bortolotto C, Draghi F. Os peroneum imaging: normal appearance and pathological findings. Insights Imaging 2017; 8 (01) 59-68
• 10 Bae WC, Ruangchaijatuporn T, Chung CB. New techniques in MR imaging of the ankle and foot. Magn Reson Imaging Clin N Am 2017; 25 (01) 211-225
• 11 Chianca V, Zappia M, Oliva F, Luca B, Maffulli N. Post-operative MRI and US appearance of the Achilles tendons. J Ultrasound 2020; 23 (03) 387-395
• 12 Draghi F, Bortolotto C, Draghi AG, Gitto S. Intrasheath instability of the peroneal tendons: dynamic ultrasound imaging. J Ultrasound Med 2018; 37 (12) 2753-2758
• 13 Rockett MS, Waitches G, Sudakoff G, Brage M. Use of ultrasonography versus magnetic resonance imaging for tendon abnormalities around the ankle. Foot Ankle Int 1998; 19 (09) 604-612
• 14 Feuerriegel GC, Sutter R. Managing hardware-related metal artifacts in MRI: current and evolving techniques. Skeletal Radiol 2024; 53 (09) 1737-1750
• 15 Kiryu S, Akai H, Yasaka K. et al. Clinical impact of deep learning reconstruction in MRI. Radiographics 2023; 43 (06) e220133
• 16 Fritz B, Fritz J, Sutter R. 3D MRI of the ankle: a concise state-of-the-art review. Semin Musculoskelet Radiol 2021; 25 (03) 514-526
• 17 Bajaj S, Chhabra A, Taneja AK. 3D isotropic MRI of ankle: review of literature with comparison to 2D MRI. Skeletal Radiol 2024; 53 (05) 825-846
• 18 Danna NR, Brodsky JW. Diagnosis and operative treatment of peroneal tendon tears. Foot Ankle Orthop 2020; 5 (02) 24 73011420910407
• 19 Drakos M, Hansen O, Kukadia S. Ankle instability. Foot Ankle Clin 2022; 27 (02) 371-384
• 20 Gribble PA, Bleakley CM, Caulfield BM. et al. 2016 consensus statement of the International Ankle Consortium: prevalence, impact and long-term consequences of lateral ankle sprains. Br J Sports Med 2016; 50 (24) 1493-1495
• 21 Acevedo JI, Mangone PG. Arthroscopic surgical technique for lateral ankle ligament instability. Foot Ankle Clin 2021; 26 (01) 65-85
• 22 Scheinberg M, Sanchez T, Sankey T. et al. Patient-reported outcomes following open Brostrom-Gould procedure: minimum 5-year follow-up. Foot Ankle Orthop 2024; 9 (01) 24 730114241228272
• 23 Alshalawi S, Galhoum AE, Alrashidi Y. et al. Medial ankle instability: the deltoid dilemma. Foot Ankle Clin 2018; 23 (04) 639-657
• 24 Hintermann B, Boss A, Schäfer D. Arthroscopic findings in patients with chronic ankle instability. Am J Sports Med 2002; 30 (03) 402-409
• 25 Finney FT, Irwin TA. Recognition of failure modes of lateral ankle ligament reconstruction: revision and salvage options. Foot Ankle Clin 2021; 26 (01) 137-153
• 26 Perez A, Vega J, Llopis E, Cerezal L. Presurgical perspective and postsurgical evaluation of instability and microinstability secondary to ankle ligaments injury. Semin Musculoskelet Radiol 2022; 26 (06) 644-655
• 27 Jesse MK, Hunt KJ, Strickland C. Postoperative imaging of the ankle. AJR Am J Roentgenol 2018; 211 (03) 496-505
• 28 Campbell KJ, Michalski MP, Wilson KJ. et al. The ligament anatomy of the deltoid complex of the ankle: a qualitative and quantitative anatomical study. J Bone Joint Surg Am 2014; 96 (08) e62
• 29 Savage-Elliott I, Murawski CD, Smyth NA, Golanó P, Kennedy JG. The deltoid ligament: an in-depth review of anatomy, function, and treatment strategies. Knee Surg Sports Traumatol Arthrosc 2013; 21 (06) 1316-1327
• 30 Lui TH. Technical tips: reconstruction of deep and superficial deltoid ligaments by peroneus longus tendon in stage 4 posterior tibial tendon dysfunction. Foot Ankle Surg 2014; 20 (04) 295-297
• 31 Nordin JS, Olsson O, Lunsjö K. The gracilis tendon autograft is a safe choice for orthopedic reconstructive procedures: a consecutive case series studying the effects of tendon harvesting. BMC Musculoskelet Disord 2019; 20 (01) 138
• 32 Pisanu F, Ortu S, Corda M. et al. Deltoid ligament reconstruction with autologous gracilis tendon in chronic medial ankle instability after ankle fracture surgery: a case report. Foot (Edinb) 2021; 49: 101714
• 33 Clanton TO, Viens NA, Campbell KJ, Laprade RF, Wijdicks CA. Anterior talofibular ligament ruptures, part 2: biomechanical comparison of anterior talofibular ligament reconstruction using semitendinosus allografts with the intact ligament. Am J Sports Med 2014; 42 (02) 412-416
• 34 Acevedo JI, Mangone P. Arthroscopic Brostrom technique. Foot Ankle Int 2015; 36 (04) 465-473
• 35 Zekry M, Shahban SA, El Gamal T, Platt S. A literature review of the complications following anterior and posterior ankle arthroscopy. Foot Ankle Surg 2019; 25 (05) 553-558
• 36 Yammine K, Assi C. Neurovascular and tendon injuries due to ankle arthroscopy portals: a meta-analysis of interventional cadaveric studies. Surg Radiol Anat 2018; 40 (05) 489-497
• 37 Poggio D, Claret G, López AM, Medrano C, Tornero E, Asunción J. Correlation between visual inspection and ultrasonography to identify the distal branches of the superficial peroneal nerve: a cadaveric study. J Foot Ankle Surg 2016; 55 (03) 492-495
• 38 Vega J, Golanó P, Peña F. Iatrogenic articular cartilage injuries during ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 2016; 24 (04) 1304-1310
• 39 Heckman DS, Reddy S, Pedowitz D, Wapner KL, Parekh SG. Operative treatment for peroneal tendon disorders. J Bone Joint Surg Am 2008; 90 (02) 404-418
• 40 Chandnani VP, Harper MT, Ficke JR. et al. Chronic ankle instability: evaluation with MR arthrography, MR imaging, and stress radiography. Radiology 1994; 192 (01) 189-194
• 41 Grant TH, Kelikian AS, Jereb SE, McCarthy RJ. Ultrasound diagnosis of peroneal tendon tears. A surgical correlation. J Bone Joint Surg Am 2005; 87 (08) 1788-1794
• 42 Maffulli N, Via AG, Oliva F. Chronic Achilles tendon disorders: tendinopathy and chronic rupture. Clin Sports Med 2015; 34 (04) 607-624
• 43 Heckman DS, Gluck GS, Parekh SG. Tendon disorders of the foot and ankle, part 2: Achilles tendon disorders. Am J Sports Med 2009; 37 (06) 1223-1234
• 44 Chen C, Hunt KJ. Open reconstructive strategies for chronic Achilles tendon ruptures. Foot Ankle Clin 2019; 24 (03) 425-437
• 45 Chen J, Janney CF, Khalid MA, Panchbhavi VK. Management of insertional Achilles tendinopathy. J Am Acad Orthop Surg 2022; 30 (10) e751-e759
• 46 Myhrvold SB, Brouwer EF, Andresen TKM. et al. Nonoperative or surgical treatment of acute Achilles' tendon rupture. N Engl J Med 2022; 386 (15) 1409-1420
• 47 Wu Y, Mu Y, Yin L, Wang Z, Liu W, Wan H. Complications in the management of acute Achilles tendon rupture: a systematic review and network meta-analysis of 2060 patients. Am J Sports Med 2019; 47 (09) 2251-2260
• 48 Maffulli N, Oliva F, Del Buono A, Florio A, Maffulli G. Surgical management of Achilles tendon re-ruptures: a prospective cohort study. Int Orthop 2015; 39 (04) 707-714
• 49 Metz R, van der Heijden GJ, Verleisdonk EJ, Andrlik M, van der Werken C. Persistent disability despite sufficient calf muscle strength after rerupture of surgically treated acute Achilles tendon ruptures. Foot Ankle Spec 2011; 4 (02) 77-81
• 50 Westin O, Nilsson Helander K, Grävare Silbernagel K, Samuelsson K, Brorsson A, Karlsson J. Patients with an Achilles tendon re-rupture have long-term functional deficits and worse patient-reported outcome than primary ruptures. Knee Surg Sports Traumatol Arthrosc 2018; 26 (10) 3063-3072
• 51 Attia AK, Mahmoud K, d'Hooghe P, Bariteau J, Labib SA, Myerson MS. Outcomes and complications of open versus minimally invasive repair of acute Achilles tendon ruptures: a systematic review and meta-analysis of randomized controlled trials. Am J Sports Med 2023; 51 (03) 825-836
• 52 Fujikawa A, Kyoto Y, Kawaguchi M, Naoi Y, Ukegawa Y. Achilles tendon after percutaneous surgical repair: serial MRI observation of uncomplicated healing. AJR Am J Roentgenol 2007; 189 (05) 1169-1174
• 53 Maffulli N, Thorpe AP, Smith EW. Magnetic resonance imaging after operative repair of Achilles tendon rupture. Scand J Med Sci Sports 2001; 11 (03) 156-162
• 54 Kosiol J, Keiler A, Loizides A. et al. Operative versus conservative treatment of acute Achilles tendon ruptures: preliminary results of clinical outcome, kinematic MRI and contrast-enhanced ultrasound. Arch Orthop Trauma Surg 2023; 143 (05) 2455-2465
• 55 Apinun J, Jenvorapoj S, Arirachakaran A, Kongtharvonskul J. Clinical outcomes of chronic Achilles tendon rupture treated with flexor hallucis longus grafting and flexor hallucis longus grafting plus additional augmentation: a meta-analysis. Foot Ankle Surg 2020; 26 (07) 717-722
• 56 Hahn F, Meyer P, Maiwald C, Zanetti M, Vienne P. Treatment of chronic Achilles tendinopathy and ruptures with flexor hallucis tendon transfer: clinical outcome and MRI findings. Foot Ankle Int 2008; 29 (08) 794-802
• 57 Koh D, Lim J, Chen JY, Singh IR, Koo K. Flexor hallucis longus transfer versus turndown flaps augmented with flexor hallucis longus transfer in the repair of chronic Achilles tendon rupture. Foot Ankle Surg 2019; 25 (02) 221-225
• 58 Moriarty MA, Morrison WB. Presurgical perspectives and post-treatment evaluation of Achilles tendon injuries. Semin Musculoskelet Radiol 2023; 27 (03) 308-313
• 59 Elias I, Besser M, Nazarian LN, Raikin SM. Reconstruction for missed or neglected Achilles tendon rupture with V-Y lengthening and flexor hallucis longus tendon transfer through one incision. Foot Ankle Int 2007; 28 (12) 1238-1248
• 60 Gluck GS, Heckman DS, Parekh SG. Tendon disorders of the foot and ankle, part 3: the posterior tibial tendon. Am J Sports Med 2010; 38 (10) 2133-2144
• 61 Abou Diwan R, Badr S, Boulil Y, Demondion X, Maynou C, Cotten A. Presurgical Perspective and Postsurgical Evaluation of Non-Achilles Tendons of the Ankle and Retinaculum. Semin Musculoskelet Radiol 2022; 26 (06) 670-683
• 62 Kamel SI, Belair JA, Hegazi TM. et al. Painful type II os naviculare: introduction of a standardized, reproducible classification system. Skeletal Radiol 2020; 49 (12) 1977-1985
• 63 Cha SM, Shin HD, Kim KC, Lee JK. Simple excision vs the Kidner procedure for type 2 accessory navicular associated with flatfoot in pediatric population. Foot Ankle Int 2013; 34 (02) 167-172
• 64 Dimmick S, Chhabra A, Grujic L, Linklater JM. Acquired flat foot deformity: postoperative imaging. Semin Musculoskelet Radiol 2012; 16 (03) 217-232
• 65 Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clin Orthop Relat Res 1989; (239) 196-206
• 66 Myerson MS. Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect 1997; 46: 393-405
• 67 Bluman EM, Title CI, Myerson MS. Posterior tibial tendon rupture: a refined classification system. Foot Ankle Clin 2007; 12 (02) 233-249 , v
• 68 Heckman DS, Gluck GS, Parekh SG. Tendon disorders of the foot and ankle, part 1: peroneal tendon disorders. Am J Sports Med 2009; 37 (03) 614-625
• 69 Mattesi L, Ancelin D, Severyns MP. Is subtalar arthroereisis a good procedure in adult-acquired flatfoot? A systematic review of the literature. Orthop Traumatol Surg Res 2021; 107 (06) 103002
• 70 Conti S, Michelson J, Jahss M. Clinical significance of magnetic resonance imaging in preoperative planning for reconstruction of posterior tibial tendon ruptures. Foot Ankle 1992; 13 (04) 208-214
• 71 Lugo-Pico JG, Kaiser JT, Sanchez RA, Aiyer AA. Peroneal tendinosis and subluxation. Clin Sports Med 2020; 39 (04) 845-858
• 72 Raikin SM, Elias I, Nazarian LN. Intrasheath subluxation of the peroneal tendons. J Bone Joint Surg Am 2008; 90 (05) 992-999
• 73 Schwartz JM, Giakoumis M, Banks AS. A simple technique for repair of chronic tendinopathy. J Foot Ankle Surg 2015; 54 (01) 143-144
• 74 Bojanić I, Knežević I, Dimnjaković D. Importance of space-occupying anatomical variations in peroneal tendoscopy. Foot Ankle Int 2021; 42 (04) 448-457
• 75 Mateen S, Ali S, Meyr AJ. Normal distal excursion of the peroneus brevis myotendinous junction. J Foot Ankle Surg 2022; 61 (06) 1158-1160
• 76 Saupe N, Mengiardi B, Pfirrmann CWA, Vienne P, Seifert B, Zanetti M. Anatomic variants associated with peroneal tendon disorders: MR imaging findings in volunteers with asymptomatic ankles. Radiology 2007; 242 (02) 509-517
• 77 Adachi N, Fukuhara K, Kobayashi T, Nakasa T, Ochi M. Morphologic variations of the fibular malleolar groove with recurrent dislocation of the peroneal tendons. Foot Ankl Int 2009; 30 (06) 540-544
• 78 Shrestha R, Sill AP, Haug LP, Patel KA, Kile TA, Fox MG. Postoperative ankle imaging, 2022. Semin Musculoskelet Radiol 2022; 26 (03) 203-215