Best Surgery for Unstable Ankle Sprain

Two million ankle sprains a year have led surgeons to develop a wide range of treatment possibilities. Most of these injuries occur along the lateral (outside -- away from the other leg) portion of the ankle. Conservative (nonoperative) care works well for many people. But when the ankle keeps giving way and/or getting resprained, it may be time to consider surgery.

Once the decision to have surgery has been made, then the next step is to consider what type of procedure to do. There are three basic options: a direct repair (take the torn ligament and reattach it to the ankle bone), reconstruct the ligament by replacing it with graft tissue, or a checkrein technique. This last option involves taking a portion of a nearby tendon (the peroneus brevis) and transferring it across the joint to the spot where the torn ligament was pulled off the bone.

There are many different pros and cons for these three approaches. The best evidence from studies done so far suggest that reconstruction has better results than either a direct repair or the checkrein procedure. By "better results" we mean fewer complications after the surgery, less pain, most normal motion, and improved proprioceptive function. Proprioception refers to the joint's sense of position, which is often damaged when the joint is injured.

Even so, there are still concerns about overtightening the joint and problems that arise with even the best reconstructive techniques. Nerve damage during the surgery, poor wound healing after surgery, and joint stiffness postoperatively have been reported with the procedures described. That's why the authors of this study came up with a new hybrid technique to reconstruct the torn ligaments in the ankle.

As the name suggests, they took two different surgical procedures and combined them together to create this new approach. The goal was to provide a more anatomic repair with fewer problems. These surgeons recognized the need to reduce problems with donor sites, position the graft with correct anatomic alignment, and avoid weak suture anchors that often pull-out easily before healing has taken place.

This hybrid procedure involves the peroneus longus tendon. They take one-third of the diameter of this tendon and transpose it to the insertion point of the torn anterior talofibular ligament (ATFL). The result is to restore normal contact points of the ankle joint, thus avoiding an overtightening situation. Putting the ankle back together as close to normal as possible may be one way to aid athletes in getting back into action on the playing field.

They tested this procedure on 57 patients ranging in age from 17 to 65. Everyone was followed for at least a year. Data is available for some patients who were in the study for up to four years. Clinical tests of ankle joint mechanical stability were done (e.g., anterior drawer test, valgus stress test, Romberg balance test). Patients answered questions about pain, motion, activity, and function.

At six weeks postop, patients were able to put their full weight on the ankle. Physical therapy began at that point. By 10-weeks after surgery, patients were started on sports-specific drills. At the end of one-full year, everyone had a mechanically stable joint. But a fair number of patients (12 per cent) were unstable with the balance tests. They could not do a one-legged stand on the surgical side without support.

These individuals were mostly recreational athletes who chose not to return to a preinjury level of sports participation. They were worried about reinjuring themselves more than aware of any true instability. Follow-up MRIs showed tendon remodeling in the donor graft but also some signs of joint changes that could eventually lead to arthritis. Long-term follow-up is intended in order to further evaluate outcomes.

The surgeon who performed all of these procedures summarized this article in two ways. First, he said that the reconstructive surgical technique for chronic, unstable lateral ankle sprains (known to surgeons as the Broström-Gould procedure) remains the gold standard. This new hybrid approach proposed and tested out is useful when the anterior talofibular ligament (ATFL) is too short to use, too frayed or damaged, or missing altogether.

In all cases, the decision to use this modified technique wasn't made until the surgeon was able to use an arthroscope and look inside the joint to see how much and what kind of damage was present. Quality of the ATFL was the determining deciding factor. Arthroscopic examination also made it possible to see if there were areas of joint capsular or synovial thickening, a sure sign of chronic instability.

For surgeons who are interested, the article contains a series of drawn figures demonstrating the necessary steps in this hybrid procedure. Incision point, access to the tendon graft, drill holes in the bone, attachment of the graft, and layering of the soft tissues over the graft are shown. A written step-by-step description is also provided. Functional rehabilitation under the supervision of a physical therapist is strongly advised.

Reference: 

John G. Kennedy, MD, MCh, MMSc, FRCS (Orth), et al. Anatomic Lateral Ligament Reconstruction in the Ankle. In The American Journal of Sports Medicine. October 2012. Vol. 40. No. 10. Pp. 2309-2317.

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