Injuries and issues affecting the ankle are some of the most common things we see at our podiatry clinic. We’ve covered a tonne of information regarding ankle conditions, particularly ankle sprains in other articles.
If you need a bit of a refresher on what an ankle sprain is, how they happen and some of the conservative treatment options available, we recommend checking out this piece – “Ankle Sprains: Signs, Symptoms, Treatments & Prevention.”
But, what if your injury is so severe that you need to consider surgery?
Why would I need ankle surgery?
It is important to note that not everyone who suffers from an ankle sprain will need surgery, in fact the literature suggests that the need for surgery is quite low.
Basically, you will have needed to sustain quite a severe injury for surgery to even be considered!
The aim of surgery is to repair or tighten the damaged ligaments to reduce their laxity.
Some people are more predisposed to ankle injuries and ligament laxity, including those with high arches (pes cavus foot type), and those with Ehlers Danlos syndrome or other ligament laxity conditions.
Studies have shown that following an ankle sprain, approximately 30% of people experience recurrent ankle sprains and chronic ankle instability (1).
There are a number of reasons as to why you may need to consider surgery following an ankle sprain. One particular study stated that surgery was indicated for patients that failed to improve their chronic ankle instability or ankle pain within 3-6 months of following conservative treatment protocols (1).
The ankle joint itself is known as a hinge joint and contains complex ligament structures to help to keep it stable.
Surgery can be performed for either acute ankle injuries or chronic instability as a result of repeated strains. It is typically advised if conservative measures have not worked, possibly due to the severity of the injury.
Residual bruising, swelling or a feeling of your ankle constantly locking or catching can also be indications for surgery.
Prior to a surgical consult, your podiatrist will usually send you for scans to get an accurate snapshot into which structures are damaged and to what extent.
The research suggests that approximately 78% of those who do not receive appropriate treatment for chronic ankle instability will develop osteoarthritis in the ankle (1).
How can I prepare for ankle surgery?
If it has been decided that surgery is the best option for you following an ankle sprain, there are a few things that you can do to allow for the best outcomes post-surgery.
This includes following the RICE principle of rest, ice, elevation and compression. Managing the swelling in the area is particularly important, as it will allow your surgeon to be able to see all the structures within your ankle much easier.
What surgical options are there?
In simple terms, ankle surgery will involve a general anaesthesia that will put you to sleep for the procedure.
Small incisions are made at a few different sites, the structures are repaired or reconstructed and the sites are closed with sutures/stitches.
There are a number of surgical options that are available and the selection of which will be best for you will depend on a number of factors.
In an ankle sprain, the most commonly injured or damaged ligaments that require repair include the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and the posterior talofibular ligament (PTFL).
Ankle surgery is known to be either reparative, which involves repairing or re-establishing ligaments within the ankle, or reconstructive which involves harvesting tendons or grafts from elsewhere in the body to produce new ligaments.
This type of surgery involves rebuilding or restoring the damaged structures by either reattaching the ends of the torn structures or shortening them to reduce their laxity. It is not the method of choice when the ligaments are completely ruptured or absent.
A type of reparative surgery is known as the Brostrom procedure. It began in 1966 and is a highly effective procedure that is often combined with an arthroscope (1). It is the most commonly performed surgery, with the literature suggesting that it is widely accepted as the surgical method of choice (2). Long term studies show that more than 90% of patients have a ‘good’ or ‘excellent’ outcome, with one study stating that the overall ankle function 10 years following surgery is approximately 90% (1). It involves a C or J shaped incision over the lateral ankle. The ligaments can be tightened using stitches or anchors that are placed in the fibula bone.
Over the years there have been many modifications to the Brostrom procedure, including:
This involves reinforcing the ligaments by pulling another structure called the extensor retinaculum towards the shin bone and stitching it to the fibula bone (1).
This can increase the strength of the structures by up to 50% (1).
This procedure is used in late repairs of lateral ankle sprains and promotes the healing where the ligament attaches to the bone (1).
The ligaments are often removed from their insertion, the scar tissue is removed and they are then reattached to the fibula using anchors (1).
Reconstructive ankle surgery involves replacing damaged and torn ligaments. Reconstruction can be known as either:
- Maintains the orientation of the ligaments (1).
- Tendon grafts are placed where the damaged ligaments insert at the bone (1).
- Useful in those with chronic ankle instability that has resulted in poor strength, generalised ligament laxity (1).
- Recreates the support in a slightly different orientation to how the ligaments would usually sit (1).
- It does not repair the ligaments and often looks at changing the direction of the peroneus brevis tendon at the lateral ankle to provide more stability (1).
Reconstructive surgery can be classed depending on the number of ligaments that are affected:
- Single ligament surgery – usually only involves the ATFL as this is the most commonly injured ligament in an ankle sprain.
- Double ligament surgery – ATFL and CFL
- Triple ligament surgery– ATFL, CFL and lateral collateral ligaments
During a reconstructive surgery, grafts or sections of the peroneal tendons (these sit on the outside of the ankle) can be used to repair a stretched or torn ATFL or CFL.
Reconstruction seems to have positive outcomes post surgically in the short term, however more study is necessary to understand its benefits in the long term (3).
Another surgical option available is known as an arthroscope, which is a minimally invasive procedure that can be used for minor repairs.
It typically involves a quicker recovery time and often anchors the damaged soft tissues to the bones which they normally attach to.
Some studies suggest that it can restore function to similar levels as reparative surgery and have the added benefits of less pain and swelling (1).
What happens after surgery?
The protocol following surgery depends on which surgery has been performed and how much damage has had to be fixed.
Typically, you will remain in a cast for the first 1-3 weeks, then moving into a moon boot for the next 4-6 weeks.
Whilst in the moon boot, simple passive range of motion exercises can begin, with more intensive physical therapy beginning 6-8 weeks post surgery (1).
Return to sport will depend on a wide range of factors, however it is generally at least 2-3 months (1).
Ankle bracing is highly recommended when returning to activity post surgically to provide stability, protection and to avoid the risk of injury.
What are the risk factors for ankle surgery?
Risks can include infection, nerve damage, stiffness in the joints or complications from anaesthesia.
These risks are determined by a number of factors including your age and general health.
If surgery does fail, an ankle fusion or full replacement may need to be considered, however this is rare.
Do you have an ankle injury?
If you have sustained an ankle injury and it does not seem to be improving with conservative treatments, contact us to chat to one of our podiatrists today. You can book online here or by calling us on 03 9432 2689.
- Camacho, L. D., Roward, Z. T., Deng, Y., & Latt, L. D. (2019). Surgical management of lateral ankle instability in athletes. Journal of athletic training, 54(6), 639-649.
- Acevedo, J. I., & Mangone, P. G. (2011). Arthroscopic lateral ankle ligament reconstruction. Techniques in Foot & Ankle Surgery, 10(3), 111-116.
- Yasui, Y., Shimozono, Y., & Kennedy, J. G. (2018). Surgical procedures for chronic lateral ankle instability. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 26(7), 223-230.