Houston Methodist. Leading Medicine

Ankle FAQ

Question:

Well, it's getting near the end of the year. Time to make a decision about my poor ankle before my insurance runs out and I have to start my deductible all over again. The surgeon says I have a chronically unstable ankle from a dozen sprains and resprains. It's all been on the outside of the ankle. Lucky me. But really I guess I am fortunate because this surgeon does something new called a hybrid ligament reconstruction. What do you guys know about this operation? Should I go with it?

Answer:

Two million ankle sprains a year have led surgeons to develop a wide range of treatment possibilities. Most of these injuries occur along the lateral (outside -- away from the other leg) portion of the ankle. Conservative (nonoperative) care works well for many people. But when the ankle keeps giving way and/or getting resprained, it may be time to consider surgery. Once the decision to have surgery has been made (like in your case), then the next step is to consider what type of procedure to do. There are three basic options: a direct repair (take the torn ligament and reattach it to the ankle bone), reconstruct the ligament by replacing it with graft tissue, or a checkrein technique. This last option involves taking a portion of a nearby tendon (the peroneus brevis) and transferring it across the joint to the spot where the torn ligament was pulled off the bone. There are many different pros and cons for these three approaches. The best evidence from studies done so far suggest that reconstruction has better results than either a direct repair or the checkrein procedure. By "better results" we mean fewer complications after the surgery, less pain, most normal motion, and improved proprioceptive function. Proprioception refers to the joint's sense of position, which is often damaged when the joint is injured. Even so, there are still concerns about overtightening the joint and problems that arise with even the best reconstructive techniques. Nerve damage during the surgery, poor wound healing after surgery, and joint stiffness postoperatively have been reported with the procedures described. That's why this new hybrid technique was developed to reconstruct the torn ligaments in the lateral ankle. As the name suggests, the surgeon takes two different surgical procedures and combines them together to create this new approach. The goal is to provide a more anatomic repair with fewer problems. This hybrid procedure uses the peroneus longus tendon. They take one-third of the diameter of this tendon and transpose or transfer it to the insertion point of the torn anterior talofibular ligament (ATFL). The result is to restore normal contact points of the ankle joint, thus avoiding an overtightening situation. Putting the ankle back together as close to normal as possible may be one way to aid patients who are chronically unstable to regain ankle stability. This procedure has been tested so far on 57 patients ranging in age from 17 to 65. Everyone has been followed for at least a year and some up to four years. At six weeks postop, the patients were able to put their full weight on the ankle. Physical therapy began at that point and by 10-weeks after surgery, the patients were started on more specific exercise drills. At the end of one-full year, everyone had a mechanically stable joint. Follow-up MRIs showed tendon remodeling in the donor graft but also some signs of joint changes that could eventually lead to arthritis. A fair number of patients (12 per cent) were unstable with the balance tests. They could not do a one-legged stand on the surgical side without support. Long-term follow-up is intended in order to further evaluate outcomes. This new hybrid reconstructive surgical technique for chronic, unstable lateral ankle sprains is most useful when the torn, ruptured, or damaged anterior talofibular ligament (ATFL) is too short to use, too frayed, or missing altogether. The final decision to use this modified technique isn't usually made until the surgeon has looked inside the joint with an arthroscope to see how much and what kind of damage is present. Quality of the ATFL is the determining deciding factor. Arthroscopic examination also makes it possible to see if there are areas of joint capsular or synovial thickening, a sure sign of chronic instability. John G. Kennedy, MD, MCh, MMSc, FRCS (Orth), et al. Anatomic Lateral Ligament Reconstruction in the Ankle. In The American Journal of Sports Medicine. October 2012. Vol. 40. No. 10. Pp. 2309-2317.

*Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.
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