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Lateral ligament reconstruction

Pre-Operation

Most patients will describe an ankle that “rolls” or “sprains” easily to the point that they avoid twisting / pivot sports, and / or uneven ground, or they are reliant on a brace to perform such activities. Even severely sprained ankles, with significant soft tissue damage, may recover if treated appropriately in the early stages following the injury. If there are any cartilage injuries, or other injuries involving the ankle joint, these are treated at the same time as the ankle reconstruction, and usually with “key-hole” surgery.

If ankle remains unstable and / or painful 6 weeks following an ankle injury, MRI may be indicated. This is largely to determine if there is a significant bone or joint injury.

Operation

The operation is performed in an operating theatre, under sterile conditions with the patient under a general anaesthetic. In most cases it is performed as a day surgery procedure.

In most cases the operation involves a tightening the lateral ligaments through a small incision over the lateral ligaments. However in cases where the ankle has been unstable for a number of years, or the patients has underlying laxity of the ligaments, or more severe injuries, the reconstruction may require the use of a graft or augmentation device.

Following the operation, the patient is placed in a fracture boot or Plaster-of-Paris back-slab, and only touch weight bearing is allowed. In most cases the patient will also be placed on a blood thinner for the first 10 days following surgery. At the first post-operative review, this wound is checked and the slab replaced with either an Aircast stirrup brace or a fracture boot (“moonboot”).

Click on the link below for a PDF version of the post-operative instructions

 

https://www.cosm.net.au/wp-content/uploads/2018/04/Ankle-stabilization.pdf

Above left - The lateral ligament repair technique. Demonstrates the sutures placed into the bone at the attachment site of the ankle ligaments and the ligaments after they have been tightened using the sutures. The operation is often performed with suture "anchors" in the bone rather than passing sutures through the bone. The Modified Brostrom-Gould procedure. a) - demonstrates the suture anchors, placed into the bone at the attachment site of the ankle ligaments. b) shows the ligaments after they have been tightened using the sutures attached to the anchors. Above right - the ligament repair with LARS augmentation. This diagram demonstrates the position of the LARS device lying superficial to the repaired native ligaments, which will be protected while they heal and soft tissues grow into the LARS ligament.

Potential
complications

Despite our best attempts, potential complications are a risk with any injury or surgical procedure. You need to be aware of these rare potential complications.

The more common ones are listed here, but please ask the surgeon if there are any you are particularly concerned about.

1. Infection

Despite the best sterile techniques, there is a low risk of wound infections (1%) and even lower risk of deep infection (fraction of 1%). These can usually be treated with a course of antibiotics, but some may need to have the wound

2. DVT or leg clots

Any lower limb injury, and / or surgery performed, carries a risk of DVT (clotting in the leg veins). Most patients will be on a low dose of a blood thinner to reduce the risk of this occurring. This may be an injection or a tablet.

3. Post-operative stiffness

This is unusual following a operation performed for instability. However it can occur following more major ankle stabilisation procedures, especially if there was also a fracture at the time of the surgery, and / or multiple ligaments were injured. On occasions this may require an arthroscopic or key-hole procedure to remove the fibrous tissue

4. Nerve injury

There may be an area of numbness distal to the incision, where the skin nerves are cut to gain access to the ankle. However this is rarely a significant problem, and it only involves the skin, and does not affect any muscles.

5. Blood vessel injury

Veins may be damaged during the surgical exposure, but this causes bruises only and these resolve with time. On rare occasions a small artery may be damaged, especially if it is an "aberrant" artery running in an unusual location. A collection of blood, hematoma or "pseudo aneurysm" may for and this would may have to be removed during a return to theatre

6. Compartment Syndrome

This is a rare complication which can occur following trauma and / or surgery. The swelling within the leg builds up to the point that it reduces blood flow into the leg. This can become a serious limb threatening complication, if not dealt with promptly. It manifest as an increasing, severe, throbbing pain and tightness in the leg. It requires surgical treatment, which includes release of the tight connective tissue enclosing the compartments of the leg.

7. Recurrent instability

The incidence of this, following a return to full sports activities, was approximately 5% over a period of 5 years, in prospective research performed by Dr. Porter. More patients present with an injury to the opposite ankle than recurrent instability in the operated ankle.

Post-Operation

POST-OPERATIVE INSTRUCTIONS AND REHABILITATION FOLLOWING ANKLE ARTHROSCOPY AND STABILIZATION

 

These are some general guidelines, however if there are any significant deviations from them you will be informed of this by your surgeon.

If at any stage you experience severe pain (not controlled with the analgesia you were given), fevers, chills, night-sweats, shortness of breath, chest pain, or any symptom about which you are concerned please make immediate contact with your surgeon, your anesthetist, the hospital where your surgery was performed, or your local emergency department

Immediately post-surgery

  • You will wake up in recovery with your operated leg in a short (below knee) cast or brace
  • The cast is to both protect the surgical site and control your pain. The cast should be left intact until seen in surgeon’s rooms for your first post-operative review.
  • The wound will be closed with dissolving sutures which do not require removal
  • The nurses will administer pain killers as required
  • You will be encouraged to move the knee and hip on the operated side
  • When you have recovered from the anesthetic, you will be allowed to mobilize with the assistance of crutches
  • You are allowed to/ not allowed to partially/ fully bear weight on the operated side depending upon surgery performed 
  • The surgeon will see you before you leave and explain the surgical findings and the procedure performed

 

From discharge until 2 weeks post surgery

  • Although you are allowed to mobilize as indicated above, when not moving around try to keep the ankle above the level of the heart to reduce the amount of swelling and pain.
  • You are encouraged to move the operated knee and hip often, and for at least 10 minutes every 3-4 hours during waking hours.

Phone Dr. Porter’s rooms to confirm the time and date of your appointment 

You may notice some bruising appearing in your toes, days to weeks following your surgery. This is bleeding from the operation site that has tracked distally under the influence of gravity and should not cause alarm.

 

First post-operative review (2 weeks)

  • The surgeon will remove the cast, check the wound and place you in an appropriate brace (will vary with type of surgery performed, the stability of the repair etc.)
  • You will also be referred for physiotherapy to supervise and monitor your rehabilitation

2-6 weeks

  • You will be allowed to weight bearing as tolerated with the brace on, and this can be with or without crutches. You should be able to walk without crutches within 4 weeks of the surgery.
  • Physiotherapy sessions will concentrate on restoring the normal range of movement in the dorsi-plantar flexion and eversion-supination directions. The physiotherapist will also instruct you in strengthening exercises in each of these directions. No inversion-supination movements are allowed until 6 weeks post surgery. You will also perform balancing exercises.

 

Second post-operative review

  • The surgeon will see you for your second post-operative review at about 6 weeks post surgery. He will check the quality of the repair and healing
  • At this stage he will usually recommend weaning yourself off the use of the brace for activities of daily living, but it should be worn for all sporting activities until told otherwise.

 

6-8 weeks

  • You should be able to swim and cycle with or without the brace on. An air cast stirrup may be recommended for these activities.

 

8-12 weeks

  • You should be able to return to running (even surfaces) wearing the air-cast stirrup.

 

12-26 weeks

  • Over this period you should be able to make a graded return to full sports activity, aiming for unrestricted sports participation within 5-6 months.

 

Air-cast stirrup

  • This should be worn until the ankle has regained full stability and is similar to the other (uninjured) ankle. However, for high-risk activities, such as volley-ball, basketball, netball, touch foot ball, orienteering etc. it is recommended that you continue to wear the air-cast brace or a lace-up ankle brace indefinitely.

 

 

Rehab / Physio

The patient will commence physiotherapy after the first post-operative review.

They are placed in either an air-cast brace, or fracture boot depending upon the intra-operative findings.

In most cases weight bearing as tolerable is allowed with the boot / brace on, progressing from partial to full weight bearing, with or without the use of crutches.

Range of motion (ROM) is allowed in all directions with the exception of no inversion-supination beyond neutral until 8 weeks post surgery, and thereafter only active ROM into inversion-supination. This is to avoid stretching out the ligaments that have been repaired or reconstructed. Resisted ROM into eversion-pronation from neutral is permitted within the first 8 weeks following surgery.

The emphasis is on the strength of the peroneus longus, brevis and tertius.

The patient is allowed to perform balance and proprioceptive work when they are able to bear weight comfortably.

Aerobic exercise can be performed on stationary bike, when tolerable, while swimming is delayed until the wounds have healed completely.

Walking without the brace is avoided until 8 weeks post surgery. Walking for exercise is to be avoided until the strength is symmetrical, foot intrinsic control regained, and gait retraining has been completed.

A graded return to running is possible when the ability to hop is symmetrical with sufficient upper body / trunk control, and increased slowly therafter.

At this stage twisting and pivoting drills, and then sport-specific skills are introduced with an expectation of return to full sport activity and competition within 4 months.