Ankle sprains are one of the most common clinical sports injuries. Approximately 80-85% of patients can recover well with various conservative treatments. However, 15-20% of patients will become chronically unstable, with residual intractable ankle pain and joint instability, and these patients will often eventually require surgery. But why do you need surgery? When should surgery be performed? What kind of surgery?
Why surgery is needed
Why do patients with chronic ankle instability need surgery? It starts with the symptoms of chronic ankle instability. Patients with chronic instability of the ankle joint can have symptoms in three areas.
1. Residual symptoms after the initial sprain of the ankle joint: these symptoms are mostly pain and swelling, which are present at the initial sprain. They are usually pain caused by local soft tissue injury during the initial sprain, including pain in the posterior lateral aspect of the ankle joint due to peroneal long and short muscle injury, swelling and pain in the ankle joint cavity due to ankle cartilage injury, pain in the medial aspect of the ankle joint due to deltoid ligament injury, pain in the lateral aspect of the ankle joint due to external ankle ligament or anterior talofibular ligament The pain in the lateral aspect of the ankle joint due to injury to the deltoid ligament, the pain in the lateral aspect of the ankle joint due to injury to the external ankle ligament or anterior talofibular ligament, etc. The injured tissue not only causes localized pain, but within the joint can further damage the joint and lead to accelerated wear and tear of other normal tissues within the joint such as cartilage; an often overlooked lesion is that of the anterior tibiofibular ligament injury and ankle instability.
2. Joint instability symptoms of ankle ligament tears: The main symptoms are recurrent ankle sprains, “ankle weakness” and a sense of fear when walking on uneven ground or in high heels. This instability not only affects the patient’s quality of life, but each sprain is a re-injury to the ankle joint, resulting in increasing laxity of the ankle joint and secondary damage to the joint and surrounding tissues. This unstable state of the ankle joint leads to increased abnormal loading of the joint during walking or exercise, which accelerates the degeneration of the joint and increases the possibility of articular cartilage damage; an often neglected etiology is the instability of the ankle joint caused by injury to the lower tibiofibular anterior ligament, which is also the cause of long-term chronic pain in the ankle joint.
3. Secondary symptoms after repeated sprains of the ankle joint: This symptom also manifests as pain and swelling in and around the joint, which gradually appears after repeated sprains of the ankle joint, and is caused by secondary lesions that occur after the instability of the ankle joint. The most common manifestation is chronic synovitis, which means that the patient can feel swelling and soreness in the ankle joint after prolonged walking. Secondary cartilage damage within the ankle joint is another major cause of joint pain in chronic instability of the ankle joint. Studies have shown that the longer the duration of chronic instability of the ankle joint, the more severe the intra-articular cartilage damage is. This secondary articular cartilage damage is mainly due to impingement from repeated ankle sprains, accelerated joint degeneration from ankle instability, and increased wear and tear of the articular cartilage from pre-existing intra-articular pathology, ultimately leading to ankle osteoarthritis. Foreign studies have confirmed that ankle instability is an important factor contributing to osteoarthritis.
Therefore, surgery is needed for chronic instability of the ankle joint, not only because it can reduce the intractable pain of the joint, rebuild the stability of the ankle joint and improve the quality of life, but mainly because it can prevent the aggravation of the disease and delay or stop the onset of advanced osteoarthritis of the ankle joint.
When should you undergo surgery.
Patients who meet one of the following criteria should undergo surgery.
1. Patients with ankle sprains who still have joint pain after 3 months and whose conservative treatment is not effective.
2. Patients who have repeatedly sprained the same ankle more than 3 times.
How to choose the surgery method.
The surgical modality differs according to the patient’s condition and can be basically divided into 3 parts.
1.Ankle arthroscopy: Ankle arthroscopy is currently the best treatment for ankle joint cavity disease. Ankle arthroscopy is performed through a tiny incision in the skin and a very fine arthroscope (2.7mm in diameter) is inserted into the ankle cavity for observation, and through other tiny incisions, equally delicate tools (such as radiofrequency, planing knife, etc.) are placed to treat the primary and secondary lesions in the chronically unstable joint of the ankle in a meticulous and comprehensive manner. The procedure is less invasive, usually requiring only one stitch, and the patient recovers quickly. Simple ankle arthroscopy cleanup surgery can be performed after waking up from anesthesia and walking on the ground.
2. Stability reconstruction surgery: Ankle stability reconstruction mainly involves reconstruction of the lateral collateral ligaments of the ankle joint, including the anterior talofibular ligament and the heel-fibular ligament.
For cases where only the anterior talofibular ligament is injured and the degree of ankle instability is relatively mild, a simple delayed repair of the lateral collateral ligament (Brostrom procedure) can be performed. This procedure is simple, minimally invasive, and has a quick recovery, with a gradual return to activity usually after 3 weeks.
However, for other patients such as those with severe ankle ligament injury, heavy weight, high sporting requirements or certain special conditions such as generalized joint laxity, ligament reconstruction surgery is used. Ligament reconstruction surgery can be divided into two ways.
(1) traditional non-anatomical ligament reconstruction: these procedures do not reconstruct the ligaments according to their original stops, so they are often prone to ankle biomechanical abnormalities, and many complications can be found during long-term follow-up, and this type of reconstruction surgery is no longer advocated.
(2) Anatomic ligament reconstruction: this surgery is based on the original ligament stops and can reconstruct the basic normal ankle biomechanics, which is the most ideal ligament reconstruction surgery at present.
Ligament reconstruction generally involves taking a segment of tendon to reconstruct the ligament, either autologous (taken from oneself) and/or allogeneic (from another person), and artificial tendons are not currently advocated for lateral ankle ligament reconstruction.
The autologous tendon can be the thin femoral tendon or the short fibular tendon. In the past, the own peroneal short tendon was mostly used because it could be removed in the same surgical incision, avoiding another surgical incision, but it is now considered that the peroneal short tendon is equally important for maintaining lateral ankle stability. Therefore, it is not reasonable to injure the short fibularis muscle, which also plays a role in maintaining stability, in order to reconstruct the stability of the ankle joint. Autologous thin femoral tendon is widely used in ACL reconstruction surgery, and it has been shown that the absence of thin femoral tendon does not cause serious sequelae after surgery.
3. Surgery related to extra-articular ankle lesions: Surgery for extra-articular ankle lesions varies according to the lesion. For persistent tarsal sinus syndrome, tarsal sinus cleanup is required; for severe heel exostosis, heel osteotomy is required; for talar subarthrosis, talar subarthrosis cleanup or fusion may be required.