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Current Reviews in Musculoskeletal Medicine logoLink to Current Reviews in Musculoskeletal Medicine
. 2020 May 4;13(3):289–297. doi: 10.1007/s12178-020-09623-1

Hamstring Autograft for Lateral Ligament Stabilization

Karan A Patel 1,✉, Taylor Cabe 1,✉, Mark Drakos 1,✉
PMCID: PMC7251021  PMID: 32367429

Abstract

Purpose of Review

This paper seeks to review the current literature and trends regarding use of hamstring autograft for lateral ankle instability.

Recent Findings

Reconstruction of the lateral ankle ligaments using hamstring autograft has been found to be an effective method to treat ankle instability in terms of patient-reported outcomes and objective measures. Biomechanically, reconstruction has been shown to be stronger (load to failure) when compared with the Broström procedure. Clinical studies have demonstrated non-inferiority when compared with the Broström procedure, with one synthetic reconstruction technique demonstrating superior outcomes.

Summary

Reconstruction of the lateral ankle ligaments using hamstring autograft is especially useful in patients who are at high risk of failure (insufficient soft tissue available for repair, ligamentous laxity, previous failed ligament repair, ossicle > 1 cm, or in the heavier, high-demand athletes).

Keywords: Lateral ankle instability, Hamstring autograft, Broström procedure

Introduction

Ankle sprains are the most common injury affecting the athlete, accounting for over 40% of all sports injuries depending on the sport [1–3]. Overall, it is estimated that there are over 2 million ankle sprains in the USA a year [4]. Majority of injuries to the ankle affect the lateral ligamentous structures, with the anterior talofibular ligament (ATFL) being the most commonly injured structure [5, 6]. Majority of ankle injuries respond well to non-operative treatment, with over 85% of individuals recovered at the 3-year time point [7]. However, a prospective cohort demonstrated that up to 40% of individuals with an acute ankle injury progress to symptoms of chronic ankle instability at 1 year out from injury [8]. Chronic ankle instability can occur due to repeated injuries to the same structures, ultimately leading to chronic laxity.

The lateral ligamentous complex of the ankle joint consists of three ligaments: anterior talofibular (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The ATFL has been found to be the weakest of the three ligaments. The main function of the ATFL is to prevent inversion of the ankle and anterior translation of the talus. Injury to this structure occurs due to inversion of the ankle in a plantarflexed position [9]. The ATFL originates on the anterior portion of the fibular head and inserts just distal to the articular margin of the talus, with the center of this insertion approximately 18 mm proximal to the subtalar joint [10]. The calcaneofibular ligament is the second most commonly injured ligament of the lateral ligamentous complex. The main function of the CFL is to prevent excessive supination of the ankle and subtalar joints. The CFL can be injured during an inversion injury with the foot in a dorsiflexed position [9]. The CFL originates from the posterior portion of the lateral malleolus and inserts onto the calcaneus at a mean angle of 133° from the long axis of the distal fibula [10]. Finally, the posterior talofibular ligament has broad origins and insertions on the posterolateral aspect of the lateral malleolus and posterolateral talus [10]. The PTFL provides restraint to inversion and internal rotation of a loaded ankle joint [11].

Indications for operative intervention for lateral ankle instability include failure of non-operative treatment (i.e., bracing, physical therapy, activity modification) in the setting of chronic lateral ankle instability. Over 50 procedures have been described for lateral ankle instability [12]. Historically, broad categories of reconstruction included non-anatomic and anatomic. While historically, non-anatomic procedures were more commonly performed, more recent literature indicates that anatomic repairs result in more physiologic motion and good clinical outcomes when compared with non-anatomic procedures [13, 14]. A very commonly performed anatomic procedure is the Broström procedure with Gould modification [15]. This involves direct repair of the injured ligaments with augmentation using the inferior extensor retinaculum [16, 17]. Previous literature indicates good long-term results with this procedure [18–21].

However, even with good clinical results, the Broström procedure with Gould modification (MBG) has a failure rate of over 10% [20–23]. This number is higher in patients who are high-demand athletes, demonstrate ligamentous laxity, have previously failed a repair, or those with confounding factors predisposing to chronic laxity [24]. More recent literature has demonstrated improved patient-reported outcomes when performing anatomic reconstruction compared with anatomic repair (MBG) in a randomized clinical trial at 2- and 5-year follow-up [22, 25]. The gold standard for graft choice for this procedure has not been defined, and the use of autograft, allograft, and synthetic graft has been described [26–32].

The use of hamstring autograft for anatomic reconstruction of the lateral ankle ligamentous complex was first described in 2000 by Paterson et al. and has since been modified and described by other authors [28, 33, 34]. The purpose of this paper is to review the current literature and trends regarding use of hamstring autograft for lateral ankle instability.

Indications

Two general categories of instability exist: mechanical instability and functional instability. Mechanical instability is defined by motion that is beyond physiologic norms for the patient. Functional instability is defined by motion that is physiologic but the patient continues to have the perception that the ankle is giving way [35]. While these categories are not always mutually exclusive, it is important to understand them as it can guide treatment. The notion exists that patients with functional instability may have strength and proprioceptive deficits that are more likely to be benefited by physical therapy [36].

Surgical consideration is warranted in patients who fail conservative management including the use of a brace and physical therapy for proprioception and ankle stabilization through peroneal muscle training and strengthening. Previous studies have demonstrated similar return to pre-injury status when comparing non-operative treatment with acute surgery [37]. When surgery is indicated, anatomic repairs such as the Broström procedure with Gould modification remain the gold standard in treatment of lateral ankle instability. It results in good clinical outcomes, even with long-term follow-up [18, 19]. However, this procedure is relatively contraindicated in patients who have insufficient soft tissue available for repair, generalized ligamentous laxity (as defined by Beighton score > 5), previous failed ligament repair, ossicle > 1 cm, or in the heavier, high-demand athletes [30, 38, 39]. Consideration to anatomic reconstruction should be made in patients with severe ankle instability as indicated by a talar tilt > 20° and anterior translation of the talus > 15 mm as measured on stress radiographs [27]. In our own experience, the senior author (M.C.D) has used similar indications for anatomic reconstructions over anatomic repair.

Preoperative Planning

Assessment of a patient with concern for chronic lateral ankle instability should include a thorough history that focuses on the length, quantity, and energy level of inversion injuries. Physical exam should include assessment of patient’s lower mechanical axis, foot alignment (cavovarus), muscular strength (peroneals), and evaluation of ankle instability with a talar tilt test and anterior drawer test. Radiographic evaluation should include standard ankle series (AP, lateral, and mortise), as well as stress radiographs (talar tilt, anterior drawer). Anterior translation is measured as the distance the talus shifts anterior in relation to the most posterior portion of the tibial and talar articular surface with the ankle in 15° of dorsiflexion [40]. Instability is defined as a talus shifts greater than 10 mm (in isolation), or greater than 5 mm difference than the contralateral side, assuming no pathology contralaterally. Recent literature advocates for numbers as low as 4 mm of absolute shift being indicative of ankle instability [41]. Instability with talar tilt which is radiographic also represents CFL incompetence, should normally be less than 10°, or less than 5° different compared with the contralateral side. The talar tilt test is performed by inverting the calcaneus, stabilizing the tibia, and holding the foot in neutral position [40]. (Fig. 1) Advanced imaging, such as magnetic resonance imaging, can be helpful to look for other intra-articular pathology that can be addressed concomitantly. Previous literature indicates the incidence of concomitant chondral injury to be as high as 95% [42, 43]. However, due to its static nature, MRI often lacks utility when diagnosing symptomatic lateral ankle instability. Up to 60% of asymptomatic patients will have torn or attenuated ATFLs on MRI [44]. After an injury to the ATLF, it often never looks normal again on MRI; however, this does not mean the patient suffers from ankle instability. Stress exams may be a more effective modality to assess the competence of the lateral structures by using dynamic testing.

Fig. 1.

Fig. 1

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Preoperative radiographs including anteroposterior (a) and lateral (b) stress images showing talar tilt of 20.8° and anterior drawer of 10.0 mm as well as standard, standing anteroposterior (c) and oblique (d) views. Increased talar tilt and anterior drawer on stress radiographs indicate for operative treatment via lateral ligament reconstruction

Surgical Technique

The technique for reconstruction of lateral ligamentous structures by the senior author (M.C.D) has been previously published [27]. The patient is positioned supine with a large bump under the ipsilateral ischial tuberosity and a tourniquet on the affected thigh. The affected leg should be prepped and draped from above the knee down in a usual sterile fashion. The tourniquet is insufflated to 250 mmHg after exsanguination of the extremity. The ankle is placed in traction, and ankle arthroscopy is performed, addressing all intra-articular pathology.

Hamstring Autograft Harvest and Preparation

A linear incision measuring approximately 3 cm should be made halfway between the tibial tubercle and the posteromedial border of the tibia beginning at the top of the tibial tubercle and moving distally. Soft tissue dissection should continue using knife and electrocautery as desired until the sartorial fascia is encountered. The sartorial fascia is cleared of adipose tissue using blunt dissection with a lap sponge. The gracilis and semitendinosus should then be identified using manual palpation. The sartorial fascia is divided on the proximal aspect of the gracilis and semitendinosus taking care not to cut too deep, as fibers of the superficial medial collateral ligament are just deep to the gracilis and semitendinosus. Metzenbaum scissors can be used to extend the opening in the sartorial fascia as needed. At this time, the decision can be made as to whether the semitendinosus, gracilis, or both tendons are to be harvested, with size being the determining factor. Ideally, the graft should be a minimum of 4 mm. Our preference is to leave the tendon of choice attached distally. Metzenbaum scissors are used to remove any adhesions between the tendon and surrounding tissues. Care should be taken to ensure all adhesions are removed in order to prevent a short graft harvest. To ensure adhesion removal, tensioning the tendon of choice should result in no medial gastrocnemius movement. Manual palpation should also be used to ensure that the tendon is free up to its hiatus.

The Linvatec tendon stripper (ConMed, Utica, NY) is used to harvest the tendon. Care should be taken to appropriately point the tendon stripper along the axis of the tendon aiming for the ischial tuberosity. The tendon is then harvested, removed distally, and brought safely to the back table for preparation. A ruler, cobb, or elevator is used to remove muscle off of the tendon. The graft is tubularized with a 0 vicryl suture using a modified Krakow Stitch. The typical length of the tendon measures between 22 and 30 cm. The typical length of the graft required ranges from 12 to 15 cm, meaning that some or all portions of this graft can be doubled as the surgeon sees fit. It is important, however, to consider the diameter of the doubled tendon and whether there is enough bony support for tunnels in the fibula, calcaneus, and talus. Typically, the tendon is doubled over to get a 4.5–5 mm diameter graft.

Reconstruction of the Lateral Ligaments Using Hamstring Autograft

A 5-cm curvilinear incision is made over the distal fibula (Fig. 2). The CFL and ATFL are dissected off the distal fibula. The peroneal tendons are protected posterior during this portion of the case. In order to facilitate graft passage later in the case, a path should be created on the deep surface of the peroneal tendons, being careful not to violate the sural nerve as it passes posterior to the peroneal tendons. After this dissection is complete, a tunnel should be drilled in the fibula. This should be directed from anteriosuperior to posterioinferior with the anterior starting point being just distal to the ankle joint. The tunnel size should be approximately the same size as the graft. Care should be taken to protect the peroneals as the tunnel is drilled. A Huston suture passer is then used to pass a looped 0 vicryl suture that can be used for shuttling at a later point. Hemostat clamp should secure the stitch.

Fig. 2.

Fig. 2

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Sites of fibular and calcaneal incisions marked and indicated by arrows. An approximately 1-cm incision is made at the lateral aspect of the calcaneus, below the peroneal tendons and an approximately 5-cm curvilinear incision is made at the distal fibula

Attention is then turned to the calcaneus. Fluoroscopy is used to create a 1-cm incision at the calcaneal insertion of the CFL (Fig. 2). This should be located just posterior to the fibula, and approximately 1 cm distal to the superior edge of the calcaneus just posterior to the peroneals. Blunt dissection is carried down to the periosteum, being careful to not injure the peroneal tendons or sural nerve. A docking tunnel is drilled at this location approximately 0.5 mm larger than the graft. A pin is used to identify location first, and once confirmed on fluoroscopy, it can be reamed using the correct size drill. The socket should measure approximately 20 mm in depth.

Attention is then turned to the talus. Identification of the ATFL insertion on the talus is performed. This is located on the anterior process of the talus, just distal to the articular surface, and approximately 18 mm from the subtalar joint. A pin with eyelet is used to identify the correct position and drilled all the way through the talus and out the medial skin between the tibialis anterior and posterior tibialis tendon. Reamer is used over the pin, again measuring the same size as the graft. A looped 0 vicryl is then passed through the tunnel by pulling the pin out of the talus from the medial side. Passing stitch is held in place with a hemostat (Fig. 3).

Fig. 3.

Fig. 3

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Passing sutures are in place and will be used to shuttle the hamstring autograft through each of the bone tunnels

Appropriate soft tissue plane is then created between the calcaneal incision and the fibular-based incision, insuring to keep this plan posterior (or deep) to the peroneal tendons. This is done with blunt dissection with a hemostat and periosteal elevator. Care is taken to avoid injury to the sural nerve. Passing stitched is placed through this appropriate soft tissue plane and held in place with hemostat (Fig. 3).

The graft is then docked in the tunnel in the calcaneus using a biotenodesis screw. Screw size should be the same or 0.25 mm larger than the tunnel based on what options one has available. Care should be taken to ensure the graft docks in the socket prior to placement of the screw. The graft is then shuttled in the appropriate soft tissue plane just posterior to the peroneal tendons. It is then passed through the fibula from posterior to anterior using the previously placed shuttling stitch. The graft is finally brought down to the talus, and through the tunnel created using the shuttle stitch (Fig. 4). A medial skin incision is made to pull the remainder of the graft out through the skin. The ankle is held in eversion and posterior translation, and the graft is fixed to the talus first and fibula using biotenodesis screw. The native ATFL and CFL are repaired and the wound is closed per the surgeon’s preference.

Fig. 4.

Fig. 4

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The graft has been pulled out of the medial aspect of the talus after being initially secured in the calcaneal bone tunnel and then passed, first, underneath the peroneal tendons, and then underneath the ATFL

The patient is made non-weight bearing with splint immobilization for 2 weeks, with aspirin for DVT prophylaxis unless other risk factors exist. The patient is then transitioned to a boot and gentle range of motion exercises is started. The patient begins advancement of weight-bearing at 4 weeks, with full weight-bearing at 6 weeks. At this time, physical therapy is initiated for proprioception, motion, and gradual strengthening. The patient returns to running at 3 months, and full clearance to sports at 6 months, depending on any other concomitant procedures performed. Postoperative stress radiographs can be performed to evaluate the reconstruction as well as tunnel position (Figs. 5 and 6).

Fig. 5.

Fig. 5

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Postoperative anteroposterior stress radiograph (a) indicating a decreased talar tilt of 5.4° and postoperative lateral stress radiograph (b) indicating a decreased anterior drawer of 7.2 mm

Fig. 6.

Fig. 6

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Postoperative anteroposterior (a), oblique (b), and lateral (c) weight-bearing radiographs show the 3 bone tunnels created in the fibula, calcaneus, and talus. Arrows indicate the sites of the bone tunnels. The fibular tunnel is seen on the anteroposterior and oblique views. Calcaneal and talar tunnels are seen on the lateral view

Current Literature (Outcomes, Complications)

Biomechanics

Previous biomechanical research indicates that the stiffness and ultimate load to failure of ATFL reconstruction using semitendinosus allograft was not significantly different than the native ATFL [45]. This data can also reasonably be assumed to be true for the use of autograft. Biomechanically, the Broström procedure was shown to have half the strength of the native ATFL [46]. This supports the current indications for anatomic reconstruction (high-demand patient, larger patient, previously failed repair, etc.). Previously, studies have also established that interference screws are superior to bone anchors in both graft elongation and mean load to failure for fixation in anatomic reconstruction of the lateral ligamentous complex [47].

Clinical Outcomes

To the authors’ knowledge, there have been 6 published studies on the use of hamstring autograft for the treatment of lateral ankle instability (Table 1). The current literature is composed of case series and comparative case series.

Table 1.

Published studies on the use of hamstring autograft for the treatment of lateral ankle instability

Author, year Study, level of evidence Type of graft No. of ankles (patients) Average follow-up (range), months Survivorship Results
Coughlin et al. (2004) Case series, IV Gracilis tendon autograft 29 (28) 23 (12–52) 100%

86% (24 patients) excellent result, 14% (4 patients) good result

AOFAS AHS

Preop 57

Postop 98 (p < .01)
Takao, et al. (2005) Case series, IV Gracilis tendon autograft 17 (17) ATLF reconstruction, 4 (4) ATFL+CFL reconstruction 24 100%

AOFAS AHS

Preop 69.4 ± 4.0

Postop 97.0 ± 2.6 points (p < .01)
Ibrahim et al. (2010) Case series, IV Gracilis tendon autograft 14 (14) 33.5 (32–48) 100%

AOFAS AHS

Preop 58

Postop 96 (p < .01)

69% (10 patients) excellent result, 31% (4 patients) good result
Xu et al. (2014) Comparative case series, III Semitendinosus autograft versus semitendinosus allograft 32 (32) autograft, 36 (36) allograft

Autograft 33.5 ± 6.7

Allograft 28.5 ± 6.7

 100% (both groups)

AOFAS AHS

Autograft

Preop 62.3 ± 8.2

Postop 95.1 ± 7.5 (p < .01)

Allograft

Preop 60.2 ± 8.4

Postop 94.8 ± 5.5 (p < .01)
Li et al. (2017) Comparative case series, III Semitendinosus autograft versus semitendinosus allograft 10 (10) autograft, 16 (16) allograft

Autograft 37.7 ± 20.8

Allograft 55.9 ± 35.5

 100% (both groups)

AOFAS AHS

Autograft

Preop 68.4 ± 10.0

Postop 94.7 ± 5.0 (p < .01)

Allograft

Preop 69.9 ± 13.3

Postop 94.8 ± 5.4 (p < .01)

Postoperative T2 MRI demonstrated more signal in allograft compared with autograft (p = .027)
Song et al. (2017) Comparative case series, III

Broström group

Semitendinosus autograft

16 (16) Broström

12 (12) autograft

Broström 16.31 ± 4.16

Autograft 19.33 ± 5.14

 100% (both groups)

AOFAS AHS

Broström

Preop 59.31 ± 7.15

6 months 86.19 ± 4.119

12 months 93.00 ± 3.950

Autograft

Preop 61.25 ± 5.39

6 months 93.25 ± 7.338

12 months 94.42 ± 5.316

AOFAS score significantly different between groups at 6-month time point only
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Coughlin et al. published the first case series on the use of hamstring autograft for the treatment of lateral ankle instability. They reported 86% of patients with excellent results and 14% with good results, based on patient satisfaction. AOFAS increased in a clinically and statistically significant way when comparing preoperative to postoperative scores [48]. Two other case series have since been published with similar results in terms of their patient-reported outcome scores. No failures are noted in any group [49, 50].

Three comparative case series currently exist in the literature [34, 51, 52]. Xu et al. reported on reconstruction of the ATFL and CFL using semitendinosus autograft versus semitendinosus allograft. Both groups have clinically and statistically significant improvements in their AOFAS scores from preop to postop, and the groups did not differ from each other. No failures were reported in either group with a mean follow-up 33.5 ± 6.7 months in the autograft group, and 28.5 ± 6.7 months in the allograft group [51]. Li et al. corroborated these findings in a comparative case series comparing semitendinosus allograft and autograft. They noted similar findings with regard to AOFAS. In addition to this, the study investigated postoperative MRI, and found increased signal on T2 MRI in the allograft group compared with the autograft group that was statistically significant. While no clinical differences were found, this could indicate improved healing and vascularity with autograft compared with allograft [52]. Finally, Song et al. investigated results following a modified Broström Gould and semitendinosus autograft. Both groups improved with regard to their AOFAS. There was a statistically significant difference in AOFAS at 6 months, with the autograft group outperforming the Broström group; however, this difference was not seen at 12 months.

Currently, there are no randomized clinical trials exist comparing hamstring autograft reconstruction to the modified Broström Gould (considered gold standard for lateral ankle instability). However, a randomized clinical trial has been performed investigating the difference between the ligament augmentation reconstruction system (LARS AC 30 DB, LARS Surgical Implants and Devices, Arc-sur-Tille, France) and the modified Broström Gould. Clinical results have been published at 2 and 5 years [22, 25]. While this does not entirely represent findings you can expect with autograft, it does give insight into an anatomic reconstruction versus modified Broström Gould. Clinical findings demonstrated statistically significant differences in total FAOS score at the 1-year, 2-year, and 5-year time points favoring the LARS group. No clinical failures were noted in the LARS group, with 2 failures noted in the modified Broström Gould [25]. A study by Drakos et al. demonstrated that autograft was better when compared with allograft, even in patients with generalized ligamentous laxity [53].

Conclusion

Reconstruction of the lateral ankle can be performed using hamstring autograft in a reliable and reproducible fashion with short-term results that are comparable with the current gold standard (MBG). Further clinical research is required to investigate the long-term outcomes following lateral ankle ligamentous reconstruction using hamstring autograft. Anatomic reconstruction using hamstring autograft is a reliable procedure for the treatment of chronic ankle instability, especially in those patients that are at greater risk of failure (i.e., insufficient soft tissue available for repair, ligamentous laxity, previous failed ligament repair, ossicle > 1 cm, or in the heavier, high-demand athletes).

Compliance with Ethical Standards

Conflict of Interest

Karan A. Patel and Taylor Cabe declare that they have no conflict of interest. Mark C. Drakos declares that he is a paid consultant for Fast Form, Extremity Medical, and Pitusan 360.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Footnotes

This article is part of the Topical Collection on Management of Ankle Instability

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Karan A. Patel, Email: Karanapatel30@gmail.com

Taylor Cabe, Email: cabet@hss.edu, Email: taylorcabe29@gmail.com.

Mark Drakos, Email: DrakosM@hss.edu.

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