What is ankle instability?
The ankle is the connection between the leg and the foot. It is a mortise joint formed by bony knuckles on the outside, inside and at the back, known as the lateral, medial and posterior malleolus, respectively. These malleoli provide attachment to ligaments which stabilise the ankle joint. Injury to the ankle can cause a sprain or disruption of these ligaments and lead to instability. Chronic ankle instability can in turn predispose to premature arthritis from repetitive trauma of the tibiotalar articulation resulting in osteochondral injury (damage to the joint cartilage and underlying bone).
What are common symptoms associated with ankle instability?
Patients who have rolled or inverted their ankle have usually injured the lateral ligament complex on the outer aspect of the ankle which includes the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). Recurrent ankle sprains typically from inversion injuries can result in pain due to synovitis or arthritis (inflammation of the joint lining or joint, respectively), and a subjective feeling of instability of the ankle when playing sports or with normal activity, especially on uneven ground. Patients with ankle instability classically describe repeated episodes of their ankle giving way or not trusting their ankle for certain activities. This is usually associated with intermittent swelling from inflammation around the ankle.
How can ankle instability be managed?
The majority of patients who have an ankle lateral ligament injury can be managed non-operatively with simple over-the-counter oral analgesia and/or oral/topical anti-inflammatory medication if not contraindicated as required, temporary rest from activity, acutely offloading their ankle for example, in a controlled ankle motion or CAM boot and with structured physical therapy. For patients with persistent instability, use of an ankle brace or strapping/taping of their ankle joint during at-risk activities and/or activity modification should be considered. Physical therapy should include ankle and foot range of motion, stretching, peroneal strengthening and proprioception (balance) exercises.
What is the surgical treatment for ankle instability?
Surgical management of patients with chronic refractory ankle lateral ligament instability who have failed non-operative strategies usually involves an inspection and clean-up of the ankle joint using a pencil-sized camera and shaver through keyhole incisions (arthroscopic debridement), then stabilisation of the lateral ligament complex via an open approach. The anterior talofibular and calcaneofibular ligaments are re-attached in a tightened functional position using suture anchors (a screw-like device with stitches to secure the ligament tissue) inserted into the lateral malleolus. Elite athletes, or patients with hypermobile joints or who have ligamentous laxity or a high body mass index may also require augmentation of their lateral ligament repair with a suture tape construct which functions like an internal brace or artificial ligament.
What is the recovery after an ankle lateral ligament stabilisation?
After your ankle lateral ligament stabilisation, you will be non-weight-bearing through your operated ankle for 4 weeks, and can then progress to protected full weight-bearing for another 8 weeks. You will be immobilised in a below-knee plaster backslab for 2 weeks, after which you can then transition to a CAM boot to be worn when ambulating only for a further 10 weeks. Once your surgical dressings have been removed after 2 weeks and your wounds are healed, you will be advised to desensitise your surgical scars by massaging your wounds with a moisturising cream/oil. For most patients, it will take 2-3 weeks for your wounds to heal, 3-4 months for your lateral ligaments to regain their functional strength, 6-7 months before you feel reasonably comfortable jogging again, and up to 12 months for the swelling in your ankle to subside and for full recovery to your new baseline level.
What can I expect after my ankle lateral ligament stabilisation?
The aim of ankle lateral ligament stabilisation surgery is to restore your function and to facilitate your return to pre-injury activities, including sports. However, it is recommended that you wear an ankle brace when you resume more physical activities or return to playing sports for at least 12 months following your operation. It is possible to re-injure your ankle lateral ligaments after your surgery. Your risk of re-injury can be reduced by adequate prehabilitation and rehabilitation, and using an ankle brace during at-risk activities during your recovery. The suture anchors used to stabilise your ligaments are buried within your bone and do not need to be removed.