Surgical Management of Chronic Ankle Sprains
Chronic or repeated ankle sprains result from incompetence for the lateral collateral ankle ligaments. These ligaments function to support and control motion within the ankle joint. When these ligaments have been damaged from previous ankle sprains, they lose their ability to restrain the ankle joint within its normal range of motion. Typical symptoms include chronic ankle pain, difficulty walking on uneven surfaces or a feeling of the ankle “giving way”. Initial treatment should consist of muscle strengthening and what is referred to as “proprioceptive rehabilitation”. This can be accomplished through a physical therapist that is knowledgeable with rehabilitation of lateral collateral ligament instability. An ankle brace may also provide some external support to prevent recurrent injuries and also control swelling.
Surgical Stabilization of the Ankle
Surgery may be indicated for those cases of chronic ankle sprains failing to respond to non-operative care. There are various surgical options available. These surgical procedures can be divided into two types. The first type involves the use of local tissue to reconstruct the lateral collateral ligament complex. The second type of surgery involves the use of a tendon graft or some other type of graft material to reconstruct the lateral collateral ligament complex.
The use of regional tissue is typically referred to as Brostrom-Gould procedure. This procedure is usually performed as an outpatient. This can be performed utilizing local anesthesia with IV sedation or a general inhalation anesthesia. The type of anesthesia depends on the surgeon and patient preference. Postoperative convalescence for this procedure includes approximately one month in a non-weight-bearing short leg cast. This is then followed by 2-3 weeks of protective weight-bearing in a brace. The patient will then progress to standard footgear. This procedure has several advantages including the use of local tissue without sacrificing normal anatomic structures, very little restriction of normal range of motion and good cosmesis with the incision placement.
The second type of surgical procedure is referred to as a tenodesis procedure. This procedure involves a tendon or fascia lata graft that is routed through drill holes within the ankle and foot bones. This is usually performed as an outpatient and requires a general inhalation or spinal anesthesia. Postoperative convalescence includes 6 weeks of non-weight-bearing in a short leg cast. This is then followed by return to standard footgear or rocker bottom brace depending on the extent of swelling. Some patients may require physical therapy but this will depend on the patient's specific situation. This procedure has the advantage of providing excellent stability. However, the stability will be at the expense of decreased joint motion and the sacrifice of normal anatomic structures to reconstruct the lateral collateral ligament complex.
The major complications following lateral ankle stabilization procedure include decrease in subtalar joint motion. This joint is primarily responsible for the foot's ability to swivel side to side. The other complication not uncommonly seen includes sural neuritis. This is secondary to excessive traction of the sural nerve during the surgical procedure. Sural neuritis is usually transient and will resolve within one year.
Lateral ankle instability that fails to respond to non-operative care may require surgical management. The type of surgical procedure depends on the patient's activity level, occupation, weight and whether or not previous surgery has failed. The patient should discuss the various options with their surgeon to determine which procedure is best for their situation. The ultimate goal is to have a patient function at their pre-injury level and perform activities of a daily living without continued ankle sprains.