What is a Lateral Ankle Reconstruction?
Ankle injuries are extremely common. They are caused by stretching or small tears in the ligaments around the ankle, which cause sprains or strains. The vast majority of ankle sprains recover fully. Occasionally the ligaments do not heal properly, which causes a feeling of instability and “giving way”. These patients may be referred to an orthopaedic surgeon, who will consider tests and surgery. Surgery is only considered after a full course of rehabilitation with physiotherapists.
The ligaments commonly responsible for instability are on the outside of your foot. Together they form the ‘lateral’ ligaments, and they stop the foot twisting inwards (‘inverting’). Sometimes an injury causes major ligament damage that needs surgery. More often, repeated over-stretching gradually damages the fibres of the ligaments and causes chronic ankle instability.
Reconstruction of these ligaments means tightening or replacing them where they have become loose or torn. Several different operations may be used. The aim is to regain the stability the ankle has lost while keeping as much movement as possible.
What is involved in this operation?
The operation is done under general anaesthetic as a day case. The ligaments are repaired through a cut on the outside of the ankle. Sometimes the surgeon also does an arthroscopy (keyhole examination) of the ankle joint at the same time to check inside the joint for damage.
Who is this operation for?
Surgery for lateral ligament instability is only recommended when non-surgical treatment has failed, including rehabilitation, braces and other support, and:
- the ankle keeps ‘giving way’ and this is troubling you or affecting your work
- The ligaments are loose when the surgeon does specific tests (for example the talar lift test)
- Imaging, such as X-rays and CT, shows injury to the ligaments
More generally, the surgeon will only recommend surgery when the likely benefit outweighs the risks. Occasionally this means people who feel their ankles are very unstable are not offered surgery, because the risks are too great or the likely benefit is small.
When the reason for the instability is unclear, your surgeon may be more cautious about recommending surgery. For example, if the ankle is loose but there is no obvious injury on imaging, you may be offered an arthroscopy first, and a reconstruction may follow.
Your surgeon can talk with you about the reasons for doing or not doing an operation. Many factors come into play. You should discuss your expectations of recovery and symptom relief with your surgeon.
What are the benefits of the operation?
Reconstruction is often very successful at stabilising the ankle. This makes walking, going up and down stairs and activities like driving much easier. A normal walking pattern may also reduce pain in other joints, such as the back.
In older people, a stable ankle can help reduce the risk of falls and the injuries they cause, 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 – nerves that supply parts of the foot may be irritated during the surgery. This can cause numbness or tingling that goes away with time. Occasionally it causes more serious nerve injury.
- 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.
More surgery is possible after any orthopaedic procedure. There are several reasons, including more drastic treatment or fixing complications. This is fairly rare, and your surgeon will discuss it if the need arises.
As with all operations, there are some general risks. These include:
- Infection. You will be given antibiotics to help prevent infection in the ankle and elsewhere, for example the lungs. Infection is more likely in people with diabetes and in smokers.
- Bleeding. If you know of any tendency to bleed (for example heavy bleeding after a dental operation), tell your doctor.
- Blood clots. Clots in the leg (deep vein thrombosis or DVT) and clots in the lung (pulmonary embolus) are a risk with all surgery. Your doctors may give you medicines and ask you to wear stockings in the days after your operation. If you or your family have a history of blood clots, tell your surgeon before the operation.
- Pain at the incision sites.
- Chest and lung complications.
For more information discuss your concerns with your surgeon.
Before the operation
Some things to arrange before you go in for 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. This is to make sure you are fit for the operation and that all the tests you need are done.
During the visit you will see a doctor, a nurse and, if necessary, an anaesthetist.
Tests
Tests that may be ordered to check you are fit for surgery include:
- blood tests
- X-ray of your Chest
- Urine Test
- ECG
Preparing Your Skin
Your skin should have no infections or irritation before surgery. If it does, contact your orthopaedic surgeon for a program to improve your skin first.
Tip
Carry a list of your medicines with you, with the name, dose and how often you take each one.
Medications
Your treating team will tell you which medicines to stop and which to keep taking before surgery. Medicines that are commonly stopped before surgery include aspirin and warfarin.
About the Operation
A lateral ankle reconstruction involves opening the ankle and repairing the ligaments that have stretched or torn. Surgeons can choose from a number of operations, and only a few are described here as examples. The surgeon will do the operation that suits you best. If you want more detail about your operation, ask your surgeon.
Before a reconstruction is considered, the surgeon will think about a simple repair of the ligaments. ‘Repair’ is simpler than reconstruction. If the ligaments have stretched, they are cut and shortened during surgery, then stitched back together. If a tendon has torn, the surgeon may be able to stitch the separated ends back together. A more advanced repair involves drilling holes into the bone and inserting clips that let the surgeon sew the ligament to 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 a basic repair is not enough to stabilise the ankle, ‘grafts’ of tissue are taken 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-stabilise the ankle.
The peroneus brevis sits on the outer surface of the lower leg and turns the ankle outwards (eversion). Another muscle, the peroneus longus, does the same, so cutting the peroneus brevis has little effect on how the foot works.
In the Evans procedure, a tunnel is drilled through the fibula bone. The peroneus brevis tendon is cut, passed through the tunnel and reattached on the other side. This creates a new stabilising force on the outer surface of the ankle.
Colville Anatomic Reconstruction
In this procedure the peroneus brevis tendon is split lengthways. It is then cut and pulled through holes drilled in both the fibula and the calcaneus bones. The free end of the tendon is stitched to part of the lateral ligament and bone.
After the Operation
You will wake up in the recovery room. Staff will keep an eye on you for an hour or two. Then you go back to the ward.
Your ankle will be in a plaster cast that comes up to just below the knee. Your leg will be raised to keep the swelling down.
Most people go home the same day. Before you leave, the nurses and physiotherapist will make sure you can walk safely on crutches without putting weight through the operated leg. They will also check that you know how to take your pain medicine and how to keep the cast dry.
Some numbness around the cuts is normal.
Call your doctor if the pain is bad and your medicine is not helping. Also call if your toes become very swollen, pale, blue or numb, if the cast gets wet or damaged, or if you get a fever.
Recovery and Rehabilitation
Most people go home the same day as the operation. You will have a plaster cast below the knee and must not put any weight through your foot for the first 10 to 14 days.
A physiotherapist will assess you for a walking aid (for example crutches) and teach you to ‘hop’ using them. You will also be shown how to go up and down stairs.
Swelling is common, especially while the wounds are healing. To reduce swelling, keep your foot raised (above the level of your heart) for 50 minutes in every hour for the first two weeks.
After 10 to 14 days you will be allowed to put weight on the foot in a special removable “walker boot”, although some people need to stay in a plaster cast. You will be advised to put more and more weight through the operated leg until you can put your full weight on it. If you have a walker boot, you may take it off to wash and do exercises, which your surgeon will advise you on.
You will be referred to physiotherapy. Over the next six weeks you will slowly build your activity up to running, while wearing the brace. At 12 weeks you should be back in normal footwear, and your physiotherapist will progress your balance, stamina and strengthening exercises.
What about pain?
While you are in hospital you will be monitored, and the medical staff will give you painkillers as prescribed. The nursing staff will tell you how to manage your pain before you leave hospital.
What will my ankle be like long-term?
Long term results depend on how severe the injury was and the type of operation used to repair the ligaments. Often the surgery is called ‘successful’ because the ankle has been stabilised, even though you may still find some tasks difficult. Physiotherapy and rehabilitation are very helpful for improving performance, but it is not always possible to return to a perfect ankle.
Try to keep your expectations about recovery realistic. To this end, discussion with your surgeon and physiotherapist about what they expect in terms of your short term and long-term outcomes will help. What you can do at home
F.A.Q.s | Frequently Asked Questions
When can I return to work?
Your own circumstances will decide when you feel ready to go back to work. If you have an office type job and can raise your leg, you should be able to return within 7 days. If your job needs a lot of walking or is strenuous, you may need 2 to 3 weeks off work. You can self-certify your sick leave for 7 days. If you need a sick certificate, please ask your GP.
When can I return to driving?
You must be free of pain and able to do an emergency stop. This also depends on which foot was operated on. If you had left sided surgery and drive an automatic car, you may be able to drive 2 to 4 weeks after surgery. Tell your insurance company which operation you have had so your cover stays valid.
What should I do if I have a problem?
If you have severe pain, a lot of swelling, inflammation or discharge, tell your GP. If you cannot contact your GP, go to the emergency department (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.