‘sprain’ – minor injury – no laxity
‘tear’ – moderate injury – laxity, soft end point
‘rupture’ – severe injury – complete loss of integrity of ligament
Acute ligament injury without fracture
No evidence of benefit of any particular treatment
Symptomatic benefit of P.O.P. immobilisation if painful
Functional recovery may be better with early movement
Elevation, ice, early weight bearing, tubigrip when mobilising
Chronic instability after injury
Proprioceptive deficit - Rx physio
Exclude Other problems
OCD dome of talus
Sinus Tarsi Syndrome
Treatment of Chronic Ligament Laxity
Multitude of described operations
Operative management of chronic ankle instability:
Damage to the articular cartilage of the ankle joint can result in a flap of surface separating from the underlying bone. These do not heal, and act as a loose body causing painful collapsing of the ankle. The surface can be hinging (left) or completely separate and loose within the joint (right).
The loose flap may be debrided leaving a base of subchondral bone. If this is drilled through to the underlying bone, the blood and fat form a clot that matures to fibrous tissue (fibrocartilage) to provide some surface, though it never forms true hyaline articular cartilage.
Lateral ligament laxity may require repair of the lateral ligaments. A 'Brostrom Repair' involves lifting the stretched and damaged ligament tissue off the front of the fibula, and running stitches through it to pull the retracted portion back onto the fibula. It can be fixed there either by running the stitch through holes in the bone, or more commonly by inserting small'suture anchors' into the bone itself.
Unfortunately the classic Brostrom repair may still leave instability, so is often augmented by use of an artificial ligament such as the Arthrex Internal Brace, which can be used to augment both the anterior talofibular ligament (ATFL) component of the lateral ligament complex, as well as the calcaneofibular ligament component (CFL).
If instability has caused an osteochondral injury, then often the two operations are combined ie ankle joint arthroscopy and lateral ligament reconstruction.
The surgery is usually performed as a day case procedure, and usually involves a general anaesthetic. The operation takes about 45 to 60 minutes depending on what may need doing in the ankle joint. There is usually two small 5mm incisions for the arthroscope, and a separate 4cm incision just in front of the lateral malleolus.
Postoperatively the ankle is usually immobilised in plaster, but if an augmentation is performed it may be possible to use a heavy bandage and a removable boot. In either scenario the ankle is kept immobilised for the first 2 weeks and the weight kept off the foot on 2 crutches until stitch removal and wound review at 2 weeks.
After 2 weeks, the boot can be removed at night or for hygiene, but the ankle kept still until 6 weeks from surgery, at which point physiotherapy is commenced.
Physiotherapy is often very prolonged; running may not be possible until 4 months post op, and by the time sport specific skills are regained it can be 6 months.
Overall however the operation is about 90% successful; this however means that 1 in 10 patients still have residual instability. Other possible complications include a wound infection in 2 to 3% of cases, and deep infection needing further surgery in about 0.5%. DVT can occur in another 2-3%; in higher risk patients (overweight, oc pill, prior history of DVT, smokers) then anticoagulant prophylaxis is given.