Surgical repair in acute lateral ankle ligament injury is a treatment modality that has not lost its place today. Of course conservative treatment by a two-week immobilization followed by functional brace with early exersices onset without loading is another successful option. In my opinion it should be decided individually. In my opinion if the injury involves only the anterior talofibular ligament conservative treatment could be a good choice. If the injury affects also the calcaneo-fibular ligament and/or posterior talofibular ligament then surgical repair is recommended to avoid chronic ankle instability. In the case of athletes surgical repair is the method of choice.

Thanks. Just suturing, or internal brace? Hagen.

In fresh injuries direct suturing is recommendable.

In fresh injuries suturing is recommendable.

Dear Hagen

The acute lateral ankle ligament ruptures specially the anterior talo fibular ligament can cause a lot of instability as ankle sprain and even malleolar fractures. In my opinion every patients who still plays some sport activity would be an ideal candidate for surgical treatment of these lesions getting conservative treatment for those with low functional demands.

Great question! In my opinion, surgical repair should be an option for all acute lateral ankle sprains with the decision made on a case by case basis. Unfortunately, there a lack of empirical data on the long-term outcomes of lateral ankle sprains (accross all severities) so it is very difficult to determine if surgical and/or conservative management resolves the alterations caused by an ankle sprain. Without high quality RCTS it is impossible to know the best treatment option but most ankle sprains are treated conservatively and epidemiological data would suggest that we may want to reconsider. For example, most reports indicate at least 33% of people who suffer an acute lateral ankle sprain develop CAI (reported as high at 74%) and about 80% of those with CAI will develop post-trauamtic ankle osteoarthritis.

The question can also be simplified to whether surgical repair produces better outcomes than conservative management.. My understanding of the current state of the literature suggests that conservative management can improve function, and so can surgery (particularly "anatomical" reconstruction). The literature does not clearly establish when one form of management is preferable over another. One of my own papers indicate that ligamentous laxity is often associated with long-term functional performance deficits, even if the patient reports good function. This suggests that there may be a role for surgery in reducing ligamentous laxity, since conservative management can treat function directly, but not change the intrinsic length of a ligament..

As far as surgical outcomes are concerned, there are long-term studies available which show functional improvement when measured by patient self-report. (E.g. Bell, S. J., Mologne, T. S., Sitler, D. F., & Cox, J. S. (2006). Twenty-six-year results after Broström procedure for chronic lateral ankle instability. The American journal of sports medicine, 34(6), 975-978.)

There are also studies which show improvement in some functional performance tests following surgery. This one compares the function of the repaired ankle to the contralateral side (Schmidt, R., Benesch, S., Friemert, B., Herbst, A., Claes, L., & Gerngross, H. (2005). Anatomical repair of lateral ligaments in patients with chronic ankle instability. Knee Surgery, Sports Traumatology, Arthroscopy, 13(3), 231-237), but it must be remembered that the contralateral limb does not always differ in a chronic situation, so a prospective dssign would have improved this study.

As Erik has said, above, there need to be more prospective studies done to improve the certainty that the surgery has changed a pre-existing deficit, and RCT's to show whether surgery is preferable to conservative management, and in what circumstances.

Dear Jeremy, the literature you cite mainly focusses on chronic instability. But what about acute rupture? Individual decision? Is the chance for long-term stability higher than the risk of operation? Do I interpret you right that you at least offer operative stabilization in active and younger patients? Best regards, Hagen.

Hi Hagen,

My aplogies, I looked at reconstruciton in chronic instability, because my automatic assumption was that a period of conservative management would be tried first, in the acute situation.

Baumhauer et al (Baumhauer, J. F., & O'brien, T. (2002). Surgical considerations in the treatment of ankle instability. Journal of athletic training, 37(4), 458) describe statistics of 80-85 % of ankle injuries recovering well with conservative management, and this is a fairly typical figure presented in other epidemiology literature for ankles. So it seems like a good clinical decision to allow this to happen without choosing to do surgery prematurely.

I am not aware of any literature that has shown (or even studied) whether surgery works better than conservative management if you make the choice early, in an acute situation. Since this literature is lacking, I doubt we will find studies which help to determine selection criteria to help clinicians to choose those patients for whom surgery would be preferable to conservative management.

As a result, we are left to rely on the clinical experince of individual experts. I agree with the opinions presented above. Multiple ligaments, inferior tib-fib diastasis, and high grade laxity (i.e. grade 3/rupture) would be criteria which encourage a surgical choice. However, I would still always prefer to delay a choice regarding surgery unless the patient's social circumstances required a quick result. Speed of return to full function would be the final yes/no criterion. This might be relevant to elite sports people or people whose income depends on a physically active job.

Best regards,

Jeremy

Never, but treat functional

Really?

"Acute repair of the lateral ankle ligaments in grade III injuries in professional athletes may give better results." cited from

Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1390-5.

Management of acute lateral ankle ligament injury in the athlete.

van den Bekerom MP, Kerkhoffs GM, McCollum GA, Calder JD, van Dijk CN.

Surgeons might be biased. Longing for occupation:-))

Dear Marcus, you are right to some extent, but not entirely. I would periphrase M. Schein: "You might be a very rich surgeon or a very good surgeon, but rarely both..."

So I hope here we are discussing on the good surgical practice. In acute injuries the surgical repair, especially for athletes and for more severe ligament injuries should be recommended.

In acute lateral ligament ruptures I do not see indications for immediate repair. As we know, talofibular anterior ligament takes care of rotational stability in ankle joint, resisting anterior translation of talus relative to fibula (and tibia) when tibia is externally rotated during stance phase of gait. Problems can be expected, if internal rotation of talus takes place before heel rise (prolonged pronation and gastrocnemius equinus or excessive supination of the foot during loading response) and/or excessive external rotation of the lower limb is targeted toward ankle joint, e.g. due to limited rotational ROM of coxae or retroversion of femoral collum.

If in chronic stage ankle instability needs operative treatment, my protocol is also to check muscular balance (especially ankle passive dorsiflxion according to Silfverskiold test) and check torsional profile of the lower limb. Operation at late stage: A-copy, ANATOMIC repair of the ligaments and if triceps surae is tight, gastro-elongation.

Only "subacute indication" for lateral ligament repair is peroneus brevis split after sprain injury. When repairing tendon split, it is practical to repair ligaments and muscular imbalance, if needed.

Sorry, Dr. Klemota, we are discussing here the acute lateral ankle ligament ruptures. I agree with the colleagues who recommend surgical repair in acute severe lateral ligament ruptures (not the isolated simple talo-fibular anterior rupture, which responds well to conservative treatment !).

As far as the "anatomic repair of the ligaments" at late stage for chronic instability which you recommend, I would express some doubt if the surgeon can find and suture the ligaments at late stage. In my opinion the reparative process changes the anatomy to such extent that their identification is rather impossible. In these chronic cases different plastic reconstruction methods are available.

I was referring to acute lateral ligament injury where talofibular ligament is the most common component. Anatomic repair in chronic cases is usually possible, even after re-rupture of sutured ligaments.

My point is, that there is a reason for chronic instability after lateral ligament injury. If we are able to recognize these risk factors, we do not need to operate immediately something nature can heal as well.

Dr. Klemota,

What you explain is a common knowledge. The point I question is that the anatomy in inveterate ligament ruptures is so changed that "anatomic repair" (in the sense of end-to-end suture !) is difficult to achieve and plastic reconstruction is usually needed (s. Campbell's Operative Orthopaedics).

You are right. But some issues are difficult to address. So I treat a lot of chronic instabilities, mainly seen following repeated distortions. But the design of RCTs usually does not allow to monitor long-term effects. Therefore, I would suggest you to start a registry for ankle ligament ruptures. Does that sound interesting for you? Hagen.

Applied load of 85N of both legs. This subluxation of the talus is the reason for surgical treatment of acute ankle instability.

Applied load of 85N of both legs. This subluxation of the talus is the reason for surgical treatment of acute ankle instability.

surgery is not superior to neuromuscular training but high at risk.

It depends on the patient.  On my high level athletes I perform an acute ligament repair with augmentation to get them back on the field or court much faster and more stable.  In the average patient I always exhaust conservative measures before considering any surgical intervention

Are you Using any augmentation ? How fast they can go back to sports ?what is your indication ? All the total atfl tears ? Or atfl and cfl? Are you using any stress test prior to surgery to assist your decision? Thank you 

why should athletes treated surgically but others not? They have the same tissues.

I do use internal brace augmentation in my athletes.  Most return to sports around 6 weeks

Dear Olga, I would never indicate an operation just based on MRI. Does the patient complain about instability? The clinical examination is very sensitive, so is the joint unstable? Looking only on the three pictures, I do not think that an operation is necessary. Rehab with training of coordination and strength might be helpful in the first place. However, if the clinical situation is clear and non-operative therapy without success, an arthroscopic Brostrøm procedure together with evaluation of the local cartilage (usually lateral or medial edge of talus) might be helpful.