Lateral ankle ligament reconstruction is performed to address ankle instability. Patients will typically have a history of recurrent ankle sprains. Their physical exam will demonstrate increased looseness of the Outside (lateral) ankle ligaments. This is often confirmed on x-rays with a stress view.

Ankle Ligament Repair Candidates

Every day an estimated one out of every 10,000 people sprain their ankle, an injury in which one of the two major ligaments on the outer portion of the ankle is stretched and/or torn. In the great majority of cases, individuals who see a physician for their injury are instructed on how to reduce pain and inflammation, may wear an air cast, participate in physical therapy to strengthen the ankle muscles, and make a full recovery.

The remaining population—about 10% of people—develop ankle instability, a condition in which, although the ligament has healed, it has done so in a lengthened position. As a result, the person is prone to a feeling of the ankle "giving out" and to additional sprains. Athletes such as ballet dancers, who already have looser-than-average ligaments, are particularly likely to develop this condition.

The orthopaedic surgeon diagnoses ankle instability through a physical assessment for mechanical instability (motion beyond the normal physiological range) and through the use of taler tilt (or stress) x-rays. In a healthy ankle, this tilt should only extend to about 5°; in the patient with an unstable ankle, the tilt will extend to 15-20° on x-ray.

Ankle Ligament Repair Outcome & Benifits

Depending upon the technique used somewhere between 80-95% chance of significant functional and symptomatic improvement.

Prepare for Ankle Ligament Repair

Treatment for ankle instability begins with a regimen of exercises intended to strengthen the muscles of the outer ankle, in an attempt to compensate for the loss of stability formerly provided by the ligament. While this treatment is helpful for many patients, it may be less successful in individuals whose muscles are already quite strong, such as dancers or other athletes. If instability is primarily a problem when participating in specific recreational activities, it may be addressed by taping the ankle and/or with the use of a brace, either one that is worn in an athletic shoe, or one that laces around the ankle. However, if these measures are not adequate to restore stability and the patient continues to experience a feeling of instability during everyday activities, surgical repair of the injury may be advised.

Ankle Ligament Repair Surgery Overview

This procedure is performed through an incision on the outside (lateral) of the ankle. The incision is opened up down to the ankle joint. The anterior talofibular ligament is identified. This ligament is typically stretched out. The dissection is usually extended down to the tip of the fibula (prominent bone on the outside of the ankle) where the calcaneofibular ligament is identified. This ligament is also often scratched out. The anterior talofibular ligament is tightened. This is done by cutting the ligament and repairing it in a tightened position with strong non-absorbable sutures. This may also be performed on the calcaneofibular ligament if this ligament is also loose. A "modification" to the Broström procedure may be added by identifying the strong extensor retinaculum and incorporating this into the repair. Following the ligament repair the wound is then closed in a layered manner.

The preferred method is an anatomic reconstruction, in which the stretched or torn ligaments is repaired and allowed to heal in a shorten position. This reconstruction can be accomplished by using the patient's own tissue, also known as a Broström procedure, or utilize a cadaver tendon, also called an allograft, if the patient's own tissue is too stretched out or different. For added stability and to help prevent re-injury, the surgeon may also tighten the retinaculum, a band of fibrous tissue that helps hold the ankle in proper alignment. The second type of surgery is peroneal substitution ligament reconstruction, a procedure in which the ligament is replaced entirely with another piece of tendon from the patient's ankle. This procedure is less ideal as the main dynamic stabilizer of the ankle, the peroneal tendon, is used.

In almost all cases, anatomic reconstruction is possible and preferable. This procedure offers the advantages of maintaining full mobility of the joint, a smaller incision, and a more rapid recovery. The primary drawback of this procedure is that ligaments may become loose a second time and require additional repairs, but this is rare. Results of the Broström procedure performed at HSS are excellent. In a case series of seventy-three patients, all but one was satisfied with the procedure and would have the procedure again.

However, anatomic reconstruction, using a patient's own tissue, is not possible in every case, for example, when the tissue have been too damaged and are insufficient for repair. When the torn ligament is too badly damaged we utilize a tendon allograft. Peroneal substitution ligament reconstruction requires a larger incision than anatomic reconstruction, has a somewhat longer recovery period, and carries a risk of nerve irritation, which can lead to chronic pain. We rarely use a non-anatomic personal substitution ligament reconstruction because it sacrifices a good tendon, has higher instances of post-operative stiffness and pain.

All types of surgery may be done using an epidural - the same type of anesthesia that many women receive during childbirth - so that the patient may be awake during their surgery if they so choose. An overnight stay in the hospital is not necessary.

Ankle Ligament Repair Recovery

Long-term outcome for both of these surgical procedures is generally quite good, provided that there is no arthritis present in the ankle. Ankle instability is not necessarily associated with ankle arthritis. However, if the bones of the ankle have been rubbing against each other over the course of many years owing to chronic ankle instability, then the latter condition may contribute to the wearing away of cartilage, and the development of arthritis in the joint.

Following surgery, the ankle is placed in a plaster splint and the patient must use crutches or a knee scooter to avoid placing any weight on the affected foot. At two weeks, the plaster splint is replaced with a cast or removable boot, which is worn for an additional 2 to 4 weeks. Formal physical therapy is started at 6 weeks and an ankle support is worn for walking until 12 weeks after surgery.

Ankle Ligament Repair After Care

Patients undergoing this type of surgery typically need a 6-week period where the ligaments are allowed to heal.  During this time, patients are either non weight-bearing or putting only limited weight through the operated extremity.  Patients are sometimes are allowed to place the ankle through a gentle range of motion in order to limit the stiffness.  At approximately 6 weeks physical therapy is usually started. 

Ankle Ligament Repair Therapy Focuses on:

1. Regaining strength about the ankle
2. Regaining motion
3. Improving proprioception
4. Returning the gait to a more normal manner.

For a number of months after surgery, the repair is often protected with an ankle lacer or equivalent.  It is common for patients to take 4-6 months to be able to return to high-level activities.

Ankle Ligament Repair Possible Risks

There are some potential risks of surgery that are specific to the lateral ligament reconstruction procedure. This includes

Injury to the superficial peroneal nerve. This nerve is often in the wound. The nerve is usually identified and is not normally cut. However, in the repair and healing process, this nerve can become scarred, leading to either decreased sensation over the top of the foot or in some cases, a painful burning sensation in this region. If this type of neuritis occurs, fairly aggressive therapy to desensitize this area is required.

Stretching out of the repair. This is another potential risk of this surgery. The repaired ligament is often strong and creates increased stability of the ankle. However, it is not as strong as the original ligament and further ankle sprains will potentially stretch out this ligament. If revision of a Brostrum repair is required many surgeons will choose to perform a tendon reconstruction of the lateral ligaments.

Patients undergoing the surgery are subject to the potential for the usual risks associated with surgery such as the risk of:

• Infection
• Wound healing problems
• Nerve injury
• Deep Vein Thrombosis (DVT)
• Pulmonary Embolism (PE)