Introduction
Ankle ligament Reconstruction (‘ALR’) is a procedure to correct ankle instability.
Indications
Surgery to correct instability of the ankle is not recommended unless all other non-surgical approaches have not helped. At around the 6-month mark – if non-surgical approaches have failed, ankle ligament reconstruction surgery may be recommended, particularly where there is continuing pain and / or swelling, where the instability leads to frequent rolling of the ankle and where it is impractical to wear a brace indefinitely.
Preoperative Instructions
You will be given a full briefing of how to prepare for your ankle ligament reconstruction procedure well in advance of the day of surgery. In very general terms you will need to…
- Let our team know what other medication you are taking and follow our guidelines on taking these medications in the days / weeks before surgery.
- This is particularly pertinent to blood thinning medications such as aspirin, warfarin, clopidogrel and Xarelto.
- Let our team know if you develop symptoms of any illness (including a cold or fever) or if you believe you may be pregnant.
- If you smoke, stop smoking ideally several days or weeks ahead of the procedure, but at the very least not smoke after midnight the night before surgery.
- Maintain your strength and mobility as best as possible, some patients attend physiotherapy prior to the surgery in preparation.
- Not eat or drink anything for a minimum of 8 hours prior to admission.
- Bring all available and relevant imaging with you to hospital.
Procedure
There are two different approaches to this procedure. In the majority of cases the first (Bröstrom procedure) will be used.
Bröstrom procedure
This is where the existing ligaments are repaired, shortened and reinforced using stitches. An incision is made over the ankle. The damaged ligaments are identified and cut a few millimeters from their attachment to the fibula bone. The cut end is advanced and sewn onto the fibula using suture anchors, the other end is folded over the top to shorten and tighten the ligament. Fibrous tissue from nearby (inferior extensor retinaculum) is sewn over the top, and in some cases, all this is reinforced with a strong “fake ligament” called an “Internal Brace”. Incisions are closed and the ankle is placed in a cast or cam walker boot.
Autologous Tendon Reconstruction
This is a similar concept to the Anterior Cruciate Ligament (‘ACL’) reconstruction for the knee. A tendon from another part of the body - often a hamstring taken from the knee, or a local tendon at the ankle - is stitched in place or attached to the bone with a screw and replaces the existing ligament.
Most procedures are conducted under general anaesthetic, and in some cases a nerve block anaesthetic is also used.
Postoperative Instructions
After the procedure you will need to stay in hospital overnight and can return home the following day. You will be given pain medication at this time. Over the first 2 weeks or so, the foot must remain in the cast or boot. You may touch it onto the ground, but do not put any substantial weight through the foot.
You will be seen for a post-op check at this time. The wound is checked, and thereafter you will usually be allowed to remove the boot for showers and gentle exercises. The exact details of timing for weight bearing, exercises, and return to activities vary with the type of surgery and the strength of the repair achieved during the operation. Mr Callahan will give you further instructions at this time.
As a typical example, patients would often wear the boot and weight bear in this for a further 4 weeks, then change to a brace that is worn inside the shoe. After 10-12 weeks the brace is used only for sport, during high risk activities, or on extreme surfaces.
Sedentary work may be resumed after 2 weeks, manual labour will typically not be possible until 6-8 weeks.
A physiotherapist can help guide you through and accelerate this recovery process.
It is very important during the recovery phase to minimise pain and swelling by elevating the affected foot as much as possible, ideally above the heart when lying or sitting. This also helps shorten the recovery time.
Risks
All surgery carries with it some form of risk. Common risks that apply to all surgery, including an ankle ligament reconstruction, are...
- Bleeding.
- Formation of a blood clot (“DVT” or deep vein thrombosis) Pieces of clot in the leg can break off and lodge in the lungs causing a pulmonary embolism. This can be very serious, and in rare cases even cause death.
- Infection.
- Nerve damage
- Difficulty getting the wound to heal
- Abnormal pain reactions or nerve hypersensitisation known as complex regional pain syndrome (CRPS)
Risks specifically related to this procedure include...
- Decreased sensation or increased sensitivity where the incision is, sometimes extending to the upper part of the foot (this occurs in around 5% of cases).
- Instability recurrence - a further surgical procedure may be required (this occurs in around 5% of cases).