Lateral ankle ligament reconstruction

Lateral ankle ligament reconstruction (also called Brostrom procedure) is a surgery to repair damaged ligaments located around the ankle. The ankle joint is formed at the junction of three bones. These include talus or the ankle bone and tibia and fibula, which are the two bones of the lower leg. The joint acts like a hinge that allows you to move the foot both up and down and sideways. The ankle joint is surrounded by ligaments that are soft and made of small fibres combined together like a rope. These ligaments hold the bones of the feet and ankle together and keep your leg stable during activities like walking. However, certain conditions or frequent ankle sprains or deformities may weaken or loosen the ligaments around the ankle joint, resulting in an unstable ankle. Brostrom procedure is recommended in such cases wherein the weakened or loosened ligaments are either stitched together or reattached to the bones around the ankle. It is usually performed by an orthopaedic foot surgeon.

A surgeon may recommend this procedure if you have ankle instability that cannot be resolved by other methods such as bracing and physiotherapy. The following are the symptoms of ankle instability:

• Repeated turning of the ankle, especially while playing sports or walking on uneven surfaces
• Tenderness or pain in the ankle
• A feeling of instability in the ankle
• Persistent swelling and discomfort in the ankle

Ankle sprain and injury are most common causes of ankle instability. You are more likely to develop ankle instability if you have any of the following leg deformities or conditions:

• Hindfoot varus (displaced position of the heel bone)
• Midfoot cavus (high longitudinal arch of the foot)
• Plantar flexion (movement of foot in which the fioot is bent away from the body at the ankle) of the first ray (the bones of the foot below the big toe) 
• Ehlers-Danlos syndrome (an inherited condition that effects joints, skin and muscles)

The surgeon will not recommend this procedure if you have any of the following conditions:

• Obesity
• Severe mechanical instability
• Poor soft tissues in the ankle region
• Peroneal weakening (Peroneus are a group of muscle in legs that make it difficult to stand on toes if they become weak)
• Isolated subtalar joint (joint located below the ankle joint) instability

The surgeon may ask you to visit the hospital for a preoperative assessment wherein the medical staff will perform a series of tests, including X-ray or magnetic resonance imaging. In addition to the tests, the surgeon may ask you:

• About your medical history, including health conditions, allergies, and history of anaesthesia,.
• To share a list of all your current medications, including prescription and over-the-counter medicines and herbal supplements.
• Whether you are pregnant.
• To discontinue taking blood-thinning medications such as warfarin, aspirin, and ibuprofen, a few days or weeks prior to the procedure
• To avoid smoking.
• About any changes in your health in the days leading up to the surgery.
• To avoid drinking or eating anything after midnight of the night before the surgery (to prevent vomiting while you are under anaesthesia.
• To sign a consent form if you agree to the procedure.
• To bring a shoe with a flat sole to wear on the unoperated feet.
• To carry comfortable clothes to wear after the procedure.
• To ask a friend, family member, or a responsible adult to drive you home after the surgery.
• To take a shower prior to the surgery.
• To remove nail polish, make-up, and body piercings before arriving at the hospital on the day of the surgery.

The surgery usually involves the following steps:

• The surgeon will administer either general anaesthesia, which will put you in deep sleep or regional anaesthesia, which will numb your body below the waist.
• A healthcare practitioner will clean the area of your ankle that needs to be operated on.
• The surgeon will make a 6- to 8-cm incision (cut) on the skin and the muscles of your ankle.
• He/she will pull aside the tissues under the skin to locate the ligaments and remove the damaged ligament.
• Next, the surgeon will make small grooves in your ankle bone to insert small screws.
• He/she will stitch weak or loose ligaments to these screws.
• The tissues present outside the ankle are also stitched to the ligament for additional support.
• Then, the surgeon will close the muscle and skin over your ankle with self-dissolving stitches, and apply a plaster over your leg.

This surgery is sometimes done with another method known as keyhole surgery, in which the surgeon makes small cuts and inserts small instruments, including a camera, into the joint to perform the procedure. There is increased swelling in the ankle after the keyhole procedure; however, the recovery period required after both the methods is nearly the same. Overall, the surgery requires at least two hours for completion.

When you regain consciousness after the surgery, a physiotherapist will visit and instruct you how to walk using crutches since you will have to use them for about two weeks to prevent any stress on the ankle. The surgeon usually discharges you on the same day of the surgery if you have arranged for someone to take you back home and accompany you overnight. However, if you experience severe pain in the ankle, the surgeon will ask you to stay at the hospital until you are comfortable.

You may be given the following instructions to take care of yourself after the surgery:

• You may experience pain for some days following the surgery. The surgeon may prescribe an appropriate painkiller for relief.
• You may be advised to keep the leg raised to reduce swelling and pain. It is okay to see mild bruising.
• You may be asked to use crutches for a few days to avoid stress on the operated ankle.
• Your plaster will be replaced by brace during one of your follow-up appointments, which you may need to wear for several weeks.
• You will be advised to undergo physiotherapy sessions for quick recovery.
• You will probably need to wait for six to eight weeks to resume driving.
• You may be allowed to resume work within some days after the procedure if you have an office job. However, if you are into heavy manual work, you may require two to three months to get back to work.
• Your doctor may allow you to indulge in sports and doing other similar activities like cycling and swimming once you are able to walk comfortably. He/she may suggest you to start with simple non-contact sports before getting into full contact sports such as football. Generally, a person needs at least six to eight months to play games like football. However, this time may vary depending on the recovery. .

The surgery provides relief from symptoms of ankle instability and the resulting pain, thus helping you walk comfortably.

When to see the doctor?

You should contact the surgeon if you experience any of the following warning signs or symptoms:

• Fever with a temperature >38°C (100.4°F).
• Discharge from or smell under the plaster.
• Increasing pain in the operated ankle or feet.
• Pain or burning sensation in the back of your leg.
• Inability to move your legs.
• Toes become swollen or bluish.
• Tingling feeling or numbness in the operated leg.

Although the possibility of complications after the surgery is unlikely, the surgery, similar to all other procedures, is associated with a few risks or complications including:

• Excessive bleeding during or after surgery
• Swelling
• Infection at the surgical site
• Permanent or temporary nerve damage or loss of sensation at or around the operated site
• Scarring
• Blood clot formation in legs
• Lack of improvement in ankle instability
• Stiffness in the ankle joint

The surgeon may ask you to visit about 10 to 14 days after the surgery to remove the plaster, examine the wound, and apply a new plaster. Once the plaster is dry, you will be allowed to walk on it. You will be asked to visit again after three weeks to remove the plaster and examine the wound. If the surgeon feels that your ankle has healed well, the plaster will be removed and you will be asked to wear an ankle brace for four to six weeks.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.