What is a Lateral Ankle Reconstruction?
Ankle injuries are extremely common, and are due to stretching or small tears in the ligaments around the ankle resulting in sprains or strains. The vast majority of ankle sprains make a full recovery. Occasionally the ligaments do not heal properly, resulting in feelings of instability and “giving way”. These patients may be referred to an orthopaedic surgeon who will consider investigations and surgery. Surgery is only considered after a full course of rehabilitation with Physiotherapists.
The ligaments commonly responsible for instability are located on the outside of your foot. Together they form the ‘lateral’ ligaments, and they stop the foot from twisting inwards or ‘inverting’. Sometimes trauma can cause major injury to the ligaments that requires surgery, but more commonly repeated over-stretching gradually damage the fibres in the ligaments causing chronic ankle instability.
Reconstruction of these ligaments involves tightening or replacing them where they have become lax or ruptured. There are a number of different operations that may be used to reconstruct the ligaments. The purpose of the reconstruction is to regain the stability the ankle has lost while keeping as much mobility as possible.
What is involved in this operation?
The operation is carried out under general anaesthesia as a day case. The ligaments are repaired through an incision on the outside of the ankle. Occasionally the surgeon also performs an arthroscopy (or keyhole examination), of the ankle joint at the same time to check the inside of the ankle joint for damage.
Who is this operation for?
Surgical therapy for lateral ligament instability will only be recommended when non-operative methods, including rehabilitation, braces and other forms of support, have failed and:
- the sensation of the ankle ‘giving way’ persists and is troubling or impacting on work
- Looseness in the ligaments is apparent when the surgeon performs specific tests (eg talar lift test).
- Imaging, like X-Rays and CTs, showing injury in the ligaments
More generally, the surgeon will only recommend surgery when the likely benefit from the operation outweighs the risks. Occasionally, this means that patients who feel their ankles are very unstable will not be recommended for surgery because either the risks are too great or the likely benefits of reconstruction are small.
When the reason for instability is unclear your surgeon may be more cautious about recommending surgery. For example, a loose ankle with no obvious injury on imaging may be recommended for arthroscopy and then a reconstruction may be performed.
Your surgeon will be able to discuss with you his reasons for doing or not doing a procedure. There are always many factors that come into play when considering an operation, and you should try to discuss your expectations of recovery and symptom resolution with your surgeon.
What are the benefits of the operation?
Reconstruction is often very successful at stabilising the ankle. It consequently makes walking, getting up and down stairs and activities like driving much easier. Furthermore, by correcting the normal walking pattern pain in other joints like the back may be reduced.
In older patients, stabilising the ankle can help reduce the risk of falls and fall-related injuries, such as hip fracture.
Complications
Complications and risks of ankle reconstruction include:
- Stiffness, swelling and pain in the ankle
- Delayed or poor healing of the wounds
- Nerve damage – typically, nerves that supply the parts of the foot may be irritated during the surgery. This can cause a numbness or tingling that disappears with time, and occasionally causes more serious injury to the nerves.
- Instability – sometimes the surgery does not completely stabilise the ankle, and sprains occur Stiffness – this is a common problem for patients who have ankle reconstruction. Generally, anatomic repair will have fewer complications than anatomic or non-anatomic reconstruction.
Follow-up surgery is a possibility in all orthopaedic procedures. There are a number of reasons for this, including more drastic interventions or addressing complications. This is fairly rare, and will be discussed by your surgeon if the need arises.
As with all operations there are a number of general risks that apply in ankle reconstruction. These include:
- Infection. You will be given antibiotics to help prevent infection in the ankle and in other areas, for example the lungs. Infection tends to be more likely in diabetics and smokers.
- Bleeding. If you are aware of any tendency to bleed (eg heavy bleeding following a dental operation) you should communicate this with your doctor.
- Blood clots. The formation of clots in the leg (deep vein thrombosis or DVT) and clots in the lung (pulmonary embolus) are a risk associated with all surgeries. Your doctors may give you medications and ask you to wear stockings in the days following your operation. If you or your family have a risk of blood clots please let us know.
- Pain at the incision sites.
- Chest and lung complications.
For more information discuss your concerns with your surgeon.
Before the operation
Some things to consider organising before you go in to surgery:
- Help with household tasks
- Food cupboards stocked up
- Help with shopping
- Help with children, pets and relatives organised for your return home
- Someone to bring you to and from the hospital
Preadmission Clinic | Preparing for Surgery
Before your operation, you will be seen at the Preadmission clinic to make sure you are fit for the operation and all the necessary tests are performed in preparation for the operation.
During the visit, you will be seen by a doctor, nurse and if necessary, an anaesthetist.
Tests
Tests that may be ordered to check you are fit for surgery include:
- blood tests
- Xray of your Chest
- Urine Test
- ECG
Preparing Your Skin
Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for a program to improve your skin before surgery.
Tip
Carry a list of your medications with you including the name, dosage and how often you take it.
Medications
Our doctors will advise you which medications you should stop or can continue taking before surgery. Common drugs that may be stopped prior to surgery include aspirin and warfarin.
About the Operation
A lateral ankle reconstruction involves opening the ankle and repairing the ligaments that have been stretched or torn. There are a number of operations available to surgeons, and only a few have been described here as examples. Keep in mind that the surgeon will perform the operation most suited to you. If you wish for more information about the specific details of your operation, ask your surgeon.
Before a reconstruction is considered, the surgeon will consider the possibility of simple repair of the ligaments. ‘Repair’ is a simpler process than reconstruction. If the ligaments have become stretched, they will be cut and shortened during surgery, then stitched back together. If the tendon has torn, the surgeon may be able to simply stitch the separated ends back together. More sophisticated repair of the ligaments involves drilling holes into the bone, then inserting clips that allow the surgeon to sew the ligament into the clips.
Anatomic Repair This is the simplest form of reconstruction. Ligaments that have torn are simply sewn back together. Ligaments that have stretched are cut, shortened then stitched together again. Often, the surgeon will increase the support around the ankle further by adjusting the position of a thick fibrous tissue called the ‘extensor retinaculum’.
When basic repair is not considered adequate to stabilise the ankle, it becomes necessary to take ‘grafts’ of tissue from other areas of the body. A common graft is the tendon of the peroneus brevis muscle.
Evans Reconstruction (Non-anatomic)
In this surgery, a muscle called the peroneus brevis is used to re-stabilse the ankle.
The peroneus brevis sits on the outer surface of the lower leg, producing outward twisting (eversion) of the ankle. Another muscle, the peroneus longus, produces the same movement, so cutting or dividing the peroneus brevis has limited affect on foot mechanics.
The Evans procedure involves drilling a tunnel through the fibula bone. The peroneus brevis tendon is then cut and run through the tunnel, then reattached on the other side. This procedure creates a new stabilising force on the outer surface of the ankle.
Colville Anatomic Reconstruction
In this procedure, the peroneus brevis tendon is split longways. It is then cut and pushed through holes drilled into both the fibula and calcaneal bones. The free end of the tendon is then stitched to part of the lateral ligament and bone.
After the Operation
Recovery and Rehabilitation
Most patients go home the same day as the operation. You will have a plaster cast below the knee, and will be required to avoid putting any weight through you foot for the first 10-14 days after your operation.
A physiotherapist will assess you for an appropriate walking aid (e.g. crutches) and teach you to ‘hop’ using them. You will also be shown how to go up and down stairs.
Swelling is common, particularly whilst the wounds are healing. In order to reduce swelling, your foot should be elevated (above the level of your heart) for 50 minutes in every hour for the first two weeks.
After 10-14 days you will be allowed to weight-bear in a special removable “walker boot”, although some patients may require the continued use of a plaster cast. You will be advised to gradually put more weight down through your operated leg, so that you can eventually put your full weight down through this leg. If you have a walker boot, you may remove it to wash and perform exercises, which your surgeon will advise you on.
You will be referred to physiotherapy, where over the next six weeks, you will gradually increase your activity to running, whilst wearing the brace. At the 12-week point, you should be back into normal footwear and your physiotherapist will progress your balance, stamina and strengthening exercises.
What about pain?
Whilst you are in hospital you will be monitored and the medical staff will give you painkillers as required and prescribed. The nursing staff will give you instructions on managing your pain before you leave hospital.
What will my ankle be like long-term?
Long term outcomes will vary depending on the severity of the injury and the type of procedure used to repair the ligaments. Often, the surgery will be considered ‘successful’ because the ankle has been stabilised, even though the patient may feel some degree of difficulty performing different tasks. Physiotherapy and rehabilitation is extremely helpful in improving performance, but it is not always possible to return to a fully functioning, perfect ankle.
It is important to have realistic expectations about your recovery. To this end, discussion with your surgeon and physiotherapist about what they expect in terms of your short term and long term outcomes is key. What you can do at home
F.A.Q.s | Frequently Asked Questions
When can I return to work?
Your own circumstances will determine when you feel ready to go back to work. If you have an office-type job and you can elevate your leg then you should be able to return to work within 7 days. If your job requires a lot of walking or is strenuous then you may need 2-3 weeks off work. Patients can self-certificate their sick leave for 7 days. If you require a sick certificate please ask your GP.
When can I return to driving?
You must be free of pain and able to perform an emergency stop. This will also depend on which foot was operated on (right or left). If you have had left sided surgery and drive an automatic car you may be able to drive 2-4 weeks following surgery. Your insurance company must be notified regarding the type of operation that you have undergone to ensure that cover is valid.
What should I do if I have a problem?
If you experience severe pain, excessive swelling, inflammation or discharge please report it to your GP. If you cannot contact your GP you should contact A&E.
References
Baumhauer, J. F., et al., ‘Surgical Considerations in the Treatment of Ankle Instability’, Journal of Athletic Training, Vol. 37, Iss. 4, Oct-Dec 2002, pp 458-462.