Ankle instability is a common complication of the so-called "ankle sprains". Instability may result from a complete break in the continuity of the ligaments, or it may be the result of the ligament not heals properly in excessive elongation. Ankle instability increases the risk of re-sprains and can lead to premature osteoarthritis that is irreversible. It manifests itself with a gradual restriction of mobility and pain while walking. Surgical treatment of ankle instability consists in repairing or reconstructing damaged ligaments, and these procedures may be preceded by arthroscopy of the ankle joint, during which intra-articular injuries are restored (the ligament reconstruction procedure itself, which in fact strengthens the joint bag or runs outside the joint, does not require exploration pond). Much less often, instability of the ankle joint develops on the basis of the insufficiency of the tricuspid ligament located on the medial side of the ankle joint.
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Ankle instability and degenerative disease
The tibia and fibula form a fork between which the talus bone is located. Due to the mutual adjustment of the articular surfaces to each other, the pressure is evenly distributed over the cartilage of the ankle joint, also known as the upper ankle joint. Changes in the adhesion of the articular surfaces to each other lead to local overloads of the articular cartilage and faster development of degenerative changes.
The loss of the perfect fit of the articular surfaces may be caused, among others, by by mechanical instability of the ankle or post-traumatic - after fracture with displacement of one of the bones. Mechanical (ligamentous) instability is an abnormal mobility of the talus in relation to the forks of the tibia and fibula due to ligamentous insufficiency of the ankle joint. Another observed type of ankle instability that does not require surgical treatment is the so-called n. functional instability in which recurrent ankle sprains occur due to neuromuscular dysfunction of dynamic ankle stabilizers with normal ligament function.
The most common type of instability is lateral instability due to discontinuity or overstretching of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). Acute instability is the complete rupture of the ATFL and / or CFL ligaments during an ankle sprain. Instability may also develop later due to poor healing of partially torn ligaments such that they remain elongated and fail to stabilize the position of the talus. In the course of lateral instability, the ankle bone moves forward relative to the ankle fork and / or tilts towards the varus. The cartilage of the ankle joint is unevenly overloaded, which leads to its faster wear and development of degenerative changes or osteo-chondral defect (OCD) on the medial side of the talus block.
The ankle-calcaneus joint is formed by the articular surfaces:
the calcaneus and talus bone (ankle-heel or subtalar joint)
the ankle bone and the navicular (ankle bone joint).
Instability of the ankle joint is less common than instability of the ankle joint. It may result from failure of the calcaneofibular ligament CFL or additional damage to the ligaments connecting the calcaneus and tibia - e.g. the tricuspid ligament.
Diagnostics of ankle instability
Mechanical instability of the ankle joint is assessed by performing the following tests:
Anterior drawer - with the stabilized distal part of the lower leg, the orthopedist pulls the heel forward to perform anterior displacement of the ankle bone in the upper ankle joint (ATFL ligament efficiency assessment);
Attempts to tilt the talus - the doctor stabilizes the distal part of the tibia with one hand and performs a forced inversion with the other, holding the talus and heel bones together (CFL and ATFL ligament efficiency assessment).
Increasing the tibio-talar distance by more than 5 mm suggests a complete rupture of the ligament or its large extension. The test should always be compared with the opposite ankle joint.
Imaging studies are very helpful in determining the degree of instability in the ankle joint. The most common is an ultrasound examination of the ankle joint. Less frequent is the assessment of the so-called stress radiographs that measure the displacement of the talus relative to the tibia in the anterior drawer test or the angle of opening of the ankle joint in the position of forced varus.
Functional instability
The cause of functional instability is a disturbance of the proprioception mechanism (deep sensation). Proprioception allows you to "feel" the position of the ankle joint without eye control. Under physiological conditions, mechanoreceptors located in the joint capsule, ligaments or tendons receive information about the current position of the joint. This information is transmitted to the central nervous system (CNS), which generates an automatic response in the form of tension in the appropriate muscles. Thanks to this, the foot automatically adjusts to the unevenness of the ground while walking and "does not run away". Twisting the ankle causes damage to the articular capsule and ligaments, which causes disturbance and impairment of neuromuscular control. The symptoms of functional ankle instability are the so-called "Ankle runaway", uncertainty when walking, and a tendency to recurrent ankle sprains despite normal ankle ligament performance.
The aim of the exercises following an ankle sprain is to improve neuromuscular control, which is to protect the ankle joint from further sprain and thus prevent re-damage to the ligaments. This is very important due to the fact that habitual ankle sprains lead to a gradual deterioration in the quality of the ligaments and the development of chronic mechanical instability and / or other cartilage damage of the ankle joint. Therefore, it is worth taking care of proper rehabilitation even after a slight sprain of the ankle joint to avoid problems with an unstable ankle in the future.
Surgical treatment of ankle instability
The surgical procedure involves repairing a damaged ligament or using a graft that replaces the function of the ligament. The indications for surgical treatment include:
complete rupture of ligaments with acute instability of the ankle joint, which seriously disturbs biomechanics and prevents the patient from returning to normal activity,
another habitual ankle sprain, which could not be reduced by conservative treatment to a state in which the patient could function freely without pain symptoms,
chronic mechanical instability with degeneration of the ankle joint, when conservative treatment does not bring the results expected by the patient, e.g. alleviating pain (but too much degeneration disqualifies ligament reconstruction / repair).
Qualification for the procedure and the choice of the surgical technique depend on many factors, sometimes it is necessary to change the decision intraoperatively
Ankle ligament repair procedures
The ATFL ligament repair procedure may involve stitching or overlapping the edges of the ligament with possible displacement of the adjacent soft tissues, e.g. the lower extensor cord. The Brostrom-Gould method or its modifications are one of the most frequently used methods of restoring tension in damaged or ineffective ATFL and CFL ligaments. The surgeon makes an incision in the anterolateral part of the articular capsule and possibly the ligaments a few millimeters from their attachments to the fibula. Then he sews the joint bag with the ligament to the fibula with the appropriate tension. For this you can additionally use anchors with non-absorbable threads, or make periosteal sutures instead. In order to strengthen this type of ligament repair, a stretched lower extensor cord can be used.
If there is an avulsive detachment of the bone fragment with the ligament, it is possible to try to fix the bone fragment again with the ligament attached to it. In recent years, the so-called technique has been widely used in ligament reconstructions in the ankle and knee joints. "internal splinting" - Internal bracing. As part of this method, strong sutures or non-absorbable polyester tapes are used, which additionally strengthen the repair performed on the patient's own tissues - in this case, a joint bag with a ligament.
Reconstruction of the lateral ligaments of the ankle joint
If suturing the ligament stumps is technically impossible, even with the use of anchors and internal bracing techniques, ligament reconstruction procedures are performed. The graft material can be harvested tendons of the following muscles: plantar, ischio-shin, long extensor of the fingers, as well as the strand of the broad fascia of the thigh ... this muscle is involved in the dynamic stabilization of the ankle joint from the lateral side. An alternative to using a patient's tendon is to use a donor tendon - that is, an allograft from a tissue bank or an artificial ligament (eg Neoligament).
Other procedures accompanying the treatment of ankle instability
Relatively often, instability of the ankle joint is accompanied by: synovial fold conflict, anterior ankle conflict or damage to the articular surface of the ankle bone block. Then, at the same time, arthroscopy is performed and the abovementioned pathologies are treated. Sometimes there are problems with the peroneal tendons - chronic inflammation, instability or longitudinal rupture - of course then it is better to perform the appropriate procedures simultaneously with the repair of the ligaments.
Rehabilitation after surgery
The procedure after repair or reconstruction procedures depends, among others, on on the operating technique used and is individually planned by the operator each time. Most often it comes down to a light, semi-rigid, thin ankle orthosis securing the ankle inversion mechanism and limiting its full mobility. During this period, the joint may be fully or partially loaded. It is recommended to discontinue the orthosis within 3-6 weeks. Passive, active-passive and active exercises are started as soon as possible, provided that the range of motion is painless and that supination is avoided until the 7th week after the surgery. Rehabilitation will also be aimed at restoring proprioception of the ankle joint, training individual phases of gait and gradually incorporating elements of a given sports discipline.
Sources:
Aronow S. Sullivan R. Skręcenia stawu skokowo-goleniowego i uszkodzenia więzadeł [w:] DiGiovanni C. Greisberg J. (Marczyński J. red.) Stopa i staw skokowo-goleniowy: Core Knowledge of Orthopaedics, Elsevier Urban&Partner, Wrocław 2010; s.254-270.
Świerczyński R. Śmigielski R. Mioduszewski A. Rekonstrukcja więzadła strzałkowo-skokowego przedniego i strzałkowo-piętowego stawu skokowego przy użyciu fragmentu ipsilateralnego ścięgna mięśnia podeszwowego Acta Clinica 2001 2:145-151.
Important information
| Duration of the procedure (depending on the method) | 45 - 120 minutes |
| Tests required for surgery | basic - preparation for surgery tab |
| Anesthesia | periosteal or subarachnoid block |
| Hospital stay | at least 4 hours after surgery |
| A period of significant dysfunction | 10 - 14 days |
| A period of limited dysfunction | 6 weeks |
| Removal of stitches - first visit | 12-16 days or not required |
| Change of dressings | every 3 - 4 days |
| Contraindications to the procedure | obesity, degeneration of the ankle joint, abnormal hindfoot axis |
Frequently asked questions about the treatment of ankle instability:
The indications for surgical treatment of ankle instability include:
complete rupture of ligaments with acute instability of the ankle joint, which seriously disrupts biomechanics and prevents the patient from returning to normal activity,
another habitual ankle sprain, which could not be brought about by conservative treatment to a state in which the patient could function freely without pain symptoms,
chronic mechanical instability, when conservative treatment does not bring the results expected by the patient, e.g. alleviating pain,
The Internal Bracing method is based on the use of strong sutures or a non-absorbable polystyrene tape, which additionally strengthens the repair performed on the patient's own tissues - in the case of the ankle joint of the articular bag with a ligament. The advantage of the Internal Bracing method is the preservation of your own ligament without the need to collect the graft and faster return to normal activity after the procedure due to the high primary strength of the implants.
Untreated chronic ankle instability increases the risk of habitual ankle sprains, subsequent cartilage and / or sagittal injuries, and leads to the acceleration of degenerative changes manifested by gradual limitation of the range of motion and ankle pain that makes walking difficult.
