Lateral instability of the ankle and results
when treated by the Evans procedure
SEPPO VAINIONPÄÄ,* M.D., PEKKA KIRVES, M.D., AND ERKKI
From the Kotka Central Hospital, Kotka, Finland
ABSTRACT
Between 1968 and 1976 81 ankles of 77 patients with lateral
instability of the ankle joint were operated on in the Kotka
Central Hospital. Sixty patients with 62 ankle surgeries had
postoperative followup.
The average follow-up time was 5.2 years and the mean age
of the patients was 28.3 years. In addition to the interview
during the postoperative examination, all patients had antero-
posterior (AP) mortice, lateral AP stress, and sagittal stress x-
ray films. In the clinical examination ankle joint mobility,
stability, peroneal function, predisposition to swelling, and
circumference of the calf were investigated.
Of the 62 ankles the result was excellent or good in 54 (87%),
satisfactory in 5 (8%), and poor in 3 cases (5%).
Of the 16 athletes’ 18 ankles treated the result was excellent
or good in 16 and satisfactory in 2 cases.
The Evans procedure prevented talar tilting and gave good
stability in anteroposterior direction.
Supination
~~upmation injury of the ankle may merely border on lateral
ligaments and other soft tissues. In ligament injuries the ante-
rior talofibular ligament always breaks first and the capsula of
the joint ruptures at the same time. The calcaneofibular liga-
ment is injured next and the posterior talofibular ligament is
rarely injured. Only a few bare ruptures of the calcaneofibular
ligament have been described in literature.2In about 25% of
the cases there is a partial or total rupture of the calcaneofibular
ligament in2 connection with rupture of the anterior talofibular
ligament. 1,2
The anterior talofibular ligament prevents lateral instability
of the ankle.3For correction of posttraumatic lateral instability
many operations have been devised. Evans’ published his own
procedure in 1953 (Fig. 1).
*
Address correspondence to Seppo Va~onpaa, M.D., Kotka Cen-
tral Hospital, 48210 Kotka 21, Fmland.
LÄIKE, M.D., Kotka,
Finland
The purpose of our study was to find out how effectively
and permanently lateral instability of the ankle could be treated
by the Evans procedure.
PATIENTS AND METHODS
Between 1968 and 1976 81 ankles of 77 patients with lateral
instability of the ankle were operated on in the Kotka Central
Hospital. The operation technique was described by Evans’ in
1953, where peroneus brevis muscle is sectioned just below the
musculotendinous junction and its belly is sutured to the
peroneus longus. The distal end is drawn down through the
proximal retinaculum. A tunnel of about 5- to 7-mm diameter
is then drilled in the lateral malleolus from the tip directed
proximally and dorsally. The tendon is then brought upward
through the tunnel and firmly sutured under good tension to
the periosteum of the fibula at either end of the tunnel (Fig. 1).
Postoperative immobilization in a below-knee walking cast was
approximately 5 weeks long and mobilization with full weight-
bearing was immediately allowed.
In 1979 all the patients operated on were invited to a follow-
up examination. Sixty patients arrived of whom 62 ankles had
been operated on. Forty of the injuries were in the right and 22
in the left ankle, 40 of the patients were men, 20 women, and
the mean age was 28.3 years, the youngest patient being 12
years and the oldest 53 years of age. The average follow-up
time was 5.2 years. Forty-two patients were regularly engaged
in sports before the operation (Table 1), and therefore the
majority were sports injuries. The origin of the traumas can be
seen in Table 2. The average time from the accident to the
operation was 3.2 years. Most of the
operation decisions were
based on either a lateral stress fluoroscopy examination or a
clinical examination (Table 3). These were compared with the
patient’s other ankle. There was no exact border for a patho-
logic fmding in fluoroscopy and the indication for operation
was based on clinical evidence of lateral ligament
insufficiency.
Lateral instability was verified in surgery and old tears of the
anterior talofibular ligament were found in all cases.
In the postoperative examination we tried to find out the
437
 joint and, after the patient had relaxed, an x-ray film was
made. Both feet were examined and the displacement of the
posterior point of the articular surface of the tibia
(,
in relation
to that of the dome of the talus was measured.5>
In clinical examination ankle joint mobility, stability, pero-
neal function, the predisposition to swelling, and circumference
of the calf were investigated. Comparisons were always made
with the contralateral foot.

RESULTS
Of the 62 ankles studied the results were excellent or good in
54 (87%), satisfactory in 5 (8%), and poor in 3 cases (5%).
In the clinical examination limitation of supination was more
than 10° in every fourth patient. No one regarded the limitation
as harmful. Four patients sustained postoperative sprains and
three had occasional pain during stress in the operated ankle.
All regarded the operation result as good. Moderate swelling
in the operated ankle was found in four cases. One patient
regarded the result as satisfactory, others had a good result.
Fig. 1. The completed Evans operation. Nobody had atrophy of the calf muscles.
The x-ray examination findings were scarce. Six patients had
slight osteoarthritis, five of whom considered the result good.
TABLE 1 One patient had pain during stress in the operated ankle and
Physical activity before mjury and after surgery therefore regarded the result as poor. His ankle was stable,
according to the investigations. Two patients had an abnormal
talar tilting; it disturbed one but the other didn’t find it too
bad. One totally symptomless patient had a fragment of bone
in the operated ankle joint. None of the patients had subluxa-
tion of the talus in the anteroposterior direction in the sagittal
stress x-ray films.
We investigated sports activity before trauma and at the
TABLE 2 postoperative examination (Table 1). There were 16 athletes in
Ongin of 56 ankle injuries the beginning and 10 of them were still active at the time of
the postoperative examination. Four athletes had totally left
the contests and were now jogging regularly. In 16 cases (18
ankles) the result was excellent or good and in two cases
satisfactory. None of them left their hobbies because of a poor
operation result.
There were no significant changes among the regularly
practicing or occasionally sporting people before the trauma or
at the time of follow-up (Table 1).
TABLE 3 The operation results were poor with three patients and none
Ways of diagnosmg preoperative instability of the 62 ankles° of them practiced sports any longer. Before the trauma two of
these patients belonged to the group of occasionally sporting
patients and the third had no sporting activity. In the first case
an abnormal talar tilting was found and the operation result
was clinically poor. The second patient had painful osteoar-
thritis but the ankle was stable. The third had an excellent
a The instability and the old rupture of the antenor talofibular result according to the physician. It was a so-called insurance-
ligament were venfied m all cases at operation.
judical case after a car accident.
After the operation two patients had a superficial wound
operated ankle’s capacity for bearing stress by interviews and infection. There was no osteomyelitis in our material.
x-ray film examinations were made which included normal x-
DISCUSSION
ray films, AP stress films, and sagittal stress films. Sagittal
stress examinations were performed with the leg elevated, There were no difficulties in the diagnosis of lateral instability
supported at the popliteal fossa and heel, in such a position of the ankle in our material. The unstable ankle after old
that the thigh was horizontal and the foot rotated 30° medially. ligament rupture is nearly painless in the examination com-
The leg was loaded with a 5-kg weight just above the ankle pared to a fresh trauma. The majority of the operation decisions
438
(87%) were based oneither a lateral stress fluoroscopy exami-
nation or barely on a clinical investigation.
Noesberger et al .6 described a standardized x-ray examma-
tion technique in 1977, where, according to them, the lateral
instability of the ankle can be shown easily and simply by
measuring the anterior subluxation of the talus in sagittal stress
x-rays. In their opinion the technique is very reliable and there
are no difficulties in interpretation as in arthrography. This
may be one of the basic examinations in the future.
Immediate surgery for ruptured ligament is recommended
with young, exercising patients 7-10 but other treatments have
been performed.11 In rupture of the lateral ligament complex
of young patients a 3- to 8-week plaster immobilization gave
good results only in 58.8% of the cases.9 If conservative treat-
ment is regarded as accurate, a walking plaster is used for 6
weeks, and after this an elastic banding for 2 to 3 weeks. 12
In lateral instability of the ankle while the talus is moving
forward, the first 3 mm distance is already significant. Now the
risk of secondary arthrosis grows, supporting surgery in the
lateral instability of the ankle for young and active people.&dquo;
We compared our results with that of three other researchers
(Table 4). Brostr6m’ used direct suture in reconstruction on 60
patients. Vrevc and Sirnik 14 had a technique, which Watson-
Jones 15, 17 described in 1940 and Ottosson used modified Evans
procedure. 11
There were excellent or good subjective results in nearly 90%
of all cases. Ottosson 16 used nearly the same kind of technique
as we but had over two and one-half times more over 10°
supination limitation cases. The difference is difficult to ex-
plain.
The predisposition to swelling, spraining, and soreness dur-
ing exercise was nearly the same in quantity when Brostrom’s’
material was compared with ours. In the Ottosson 16 material
there were proportionately more of the above-mentioned facts
than in our material, even though his subjective results were
better. We used the original J-shaped incision described by
Evans’ which goes behind the fibula curving down forwards.
No suralis nerve injuries will occur then and the predisposition
to swelling is obviously less, compared with an incision crossing
straight over the fibula.
TABLE 4
Comparison of our results with three other researchers
We tried to clarify the quality and duration of treatment
during the original injury but had to give this up. It proved too
hard to clarify reliably because part of the traumas had hap-
pened 10 to 25 years ago and the majority of them were treated
in hospitals elsewhere.
ACKNOWLEDGMENT
The authors wish to thank Dr. K. E. Kallio, Jr., from the First
Department of Surgery, University Central Hospital, Helsinki,
who has kindly given good advice in our work.
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