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Mr Peter Ammon MBBS (WA), FRACS (Orth)

CONSULTING & OPERATING
St John of God Hospital Murdoch

Direct Line (08) 6332 6300 Fax (08) 6332 6301 Email reception@peterammon.com

Ankle Arthroscopy and Ankle Ligament Reconstruction

Ankle Arthroscopy (keyhole surgery) involves examination and surgery inside the ankle joint through two or three small incisions in the skin. This enables the problem with your ankle to be assessed and treated at the same time.

The surgery is usually performed as a day case procedure under a general anaesthetic. I do put in a local anaesthetic ankle block which minimises the amount of general anaesthetic required and gives excellent pain relief after the operation.

I use an ankle distractor in the majority of cases which improves access to the ankle joint and minimises any damage to the cartilage.

Conditions that commonly require ankle arthroscopy

  • Loose fragments of bone or cartilage
  • Treatment of bony or cartilage defects
  • Scarring of joint lining
  • Excess scar tissue after injury
  • Biopsy

It is standard after the surgery to stitch the wounds closed with a single stitch and apply a bulky, well padded dressing. After the surgery, your foot and ankle should be numb and pain free. You will need to use crutches for the first few days. The first postoperative review is ten days after surgery. Physiotherapy may be started at this time if felt necessary.

It is important to keep the foot well elevated to reduce swelling and pain. A guide to the amount of elevation required is: the tip of your nose should line up with the big toe.

Complications of Surgery

You should be aware that all surgery has a risk of complications and this surgery is no different.

There are medical complications such as heart attack, stroke, drug reaction, blood clots in the legs or lungs and even death in very rare circumstances.

The chance of one of these happening is very small and is reduced by doing the surgery as a day case and using local anaesthetic.

Surgical complications include:

  • Infection: antibiotics are given before and after surgery to reduce the chance of infection, but cannot eliminate it.
  • Nerve injury: can result from the small sensory nerves being caught up in scar tissue and may leave an area of numbness over the toe, or occasionally an area of sensitivity that may require another procedure.
  • Wound healing: problems are rare and tend to happen in diabetics and smokers. If you do smoke you should stop smoking for at least four weeks around the operation.

Surgery is very effective in the vast majority of patients with at least nine out of ten being happy with the result.

However, it is possible, although very unlikely, to be made worse by surgery if a complication develops that cannot be easily fixed.

Ankle Arthroscopy Ankle Ligament Reconstruction

It is common to perform an arthroscopy of the ankle prior to ligament reconstruction and this is the reason to combine these topics in the same brochure.

Ankle instability results from a single severe injury or repeated minor sprains of the ankle. When the ankle ligaments on the outside of the ankle are torn (ATFL and CFL), they often heal in a lengthened fashion. This results in loose ligaments and a sloppy ankle.

For some patients, rolling of the ankle occurs only when playing sport. For others, it may occur when walking on uneven ground or rough surfaces.

Ankle sprains are very common but most do not need surgery. The majority will need only physiotherapy and the use of a brace for sport.

Surgery is indicated for those who:

  • Continue to have pain or swelling
  • Cannot or will not wear a brace indefinitely
  • Have such severe instability that rolling the ankle occurs very frequently.

Each time the ankle rolls, it causes pain and often swelling. It also risks injuring the cartilage of the ankle joint, which may lead to arthritis.

Surgery

Surgery is extremely effective at correcting this instability but does require a prolonged recovery. The operation is performed as an overnight stay. Usually a general anaesthetic is used and is supplemented by a local anaesthetic ankle block that I administer. The local anaesthetic reduces the amount of general anaesthetic required and gives excellent pain relief after the operation.

The surgery involves tightening up the ligaments on the outside of the ankle. This is done by peeling the ATFL ligament off the fibula bone and reattaching it. The ligament is then placed in a tightened position by using stitches and anchors through the bone itself.

An artificial ligament is added to strengthen the repair and allow early movement. It may be necessary to explore nearby tendons and repair any tears at the same time. This will be decided before surgery. The surgical repair is protected in a plaster for two weeks then four weeks in a moonboot. Crutches are needed for the first two weeks while in a cast.

Postoperative Course

You can return home the next day or the day after, depending on your preference. You will be given painkillers and antibiotics to go home with. It is important to keep the foot elevated as much as possible over the first two weeks to allow the wound to heal.

After the first two weeks in a cast, it is changed to a moon boot. You can start weight bearing on the boot straight away. The boot can be removed for showering and exercises. Physiotherapy also starts now to mobilise and strengthen the ankle.

After four weeks in the boot it is changed to a lace up ankle brace. This is used for the next 2 weeks as a step down from the boot. After that it is only necessary to wear the brace when playing sport in the first three months.

It is important not to underestimate the time taken to recover from foot surgery. As the foot is the lowest part of the body, swelling is always a problem. Swelling causes pain and delays recovery. It is therefore important to elevate the foot as much and as often as possible. It is important to allow two weeks off work as a minimum for office duties and at least six weeks off manual labouring type work.

Complications of Surgery

You should be aware that all surgery has a risk of complications and this surgery is no different.
There are medical complications such as heart attack, stroke, drug reaction, blood clots in the legs or lungs and even death in very rare circumstances.

The chance of one of these happening is very small.

Surgical complications are the same as arthroscopy but include:

  • Recurrence of instability: it is possible for the repaired ligament to stretch out again. This happens in approximately one in twenty patients or 5% and may require further surgery.

Surgery is very effective in the vast majority of patients with at least nine out of ten being happy with the result.

However, it is possible although very unlikely, to be made worse by surgery if a complication develops that cannot be easily fixed.

A more detailed discussion of your individual case will be made at the consultation.