Case Study by Mike Karski

Patient Details

  •   25 year old male
  •   Works in catering
  •  Enjoys football and running as hobbies

 

Key Learning Points

Augmentation of an ankle lateral ligament reconstruction with a synthetic ligament is a good option in cases where the remnant ATFL scar tissue is thin, and this technique can allow an accelerated rehabilitation post operatively.

Case Background

This gentleman injured his ankle 1 year previously (inversion injury) playing football. He had recurrent episodes of instability, with his ankle regularly giving way in inversion and he was apprehensive when walking on uneven ground.
Minimal pain day to day but he experienced lateral ankle pain and swelling each time his ankle instability occurred.
The examination findings were: severe instability with laxity on anterior drawer test and inversion stress testing, compared to the opposite ankle. Peroneal tendons normal.
MRI scan revealed chronic lateral ligament sprain with ATFL difficult to visualize (absent), + previous injury to CFL. Articular surfaces and peroneal tendons normal.

What treatment did you recommend / undertake

  • The patient had a 3 month course of physiotherapy including proprioceptive exercises and eversion strengthening with no improvement in symptoms. 
  • The patient was then offered the option of arthroscopy and lateral ligament reconstruction; I routinely recommend anatomical reconstruction with a modified Brostrom technique.
  • In this case, in view of the ATFL being very thin and attenuated, I augmented the standard Brostrom technique with a synthetic “Internal Brace” ligament over the remnant of the ATFL, secured into the fibula and talus with plastic PEEK screws to give a very stable ligament reconstruction, rather than relying on the thin scarred remnant of the ATFL.

 

What post operation rehab was required?

  • Post operatively he was placed in a backslab plaster for the first 2 weeks 
  • 2 weeks post op the sutures were removed and he was allowed to mobilise in an aircast boot .The extra stability of the internal brace allows increased weight bearing up to full weight bearing from 2-6 weeks, rather than partial weight bearing. The boot was removed intermittently by week 2-6 for active dorsiflexion and plantarflexion exercises (avoiding inversion)
  • 6 weeks post surgery he was mobilising fully weight bearing in an aircast splint to avoid inversion for a further 2 weeks
    Passive inversion exercises were avoided until 12 weeks post surgery to avoid overstretching of the ligament reconstruction. Lateral ligament reconstruction was clinically very stable. Built up to proprioceptive exercises and eversion strengthening week 6-12 post op
  • 12 weeks post op rehab was built up to running. At this stage the patient’s ankle felt stable, pain free and he had full relief of instability symptoms.

What were the challenges, and how was this case unique?

The augmentation of the lateral ligament reconstruction with a synthetic ligament (Internal brace) is a useful technique, resulting in a very stable reconstruction in cases where the ATFL remnant scar tissue is thin.
Due to the stability of the construct, it allows earlier full weight bearing than a standard Brostrom lateral ligament reconstruction, with the benefit of accelerated post operative rehabilitation.