Ankle Ligament Reconstruction (Brostrom Operation)

What alternatives do I have instead of this surgery?

Surgery to stabilise the ligaments is not always needed after an ankle sprain. In fact most people manage to rehabilitate with Physiotherapy.
Some people who are very hypermobile or have ligament laxity or those with a high arch foot may recover slower. Insoles and ankle braces can be helpful in some cases.

Patients with a high arch will particularly benefit from orthotics to stabilise the ankle.

What is done during the operation?

This is normally a day surgical procedure performed under general aneasthetic. The incision is about 5 cm long and it is curved on the outside of your ankle. There are various repair techniques but we use two small 3mm metal anchors to repair the injured ligaments back onto the fibula bone.
The surgery takes around 45 min. The surgical incision is closed with absorbable sutures.
During surgery a tourniquet is wrapped around your upper thigh to stop blood obscuring the operative filed. You may sometimes feel some soreness around your thigh for a day or two post op as a result.
After the operation you will be placed in a below the knee plaster backslab. This is a half plaster with bandaging around. You will not be allowed to weightbear and will be given crutches to use.

What are the risks of this operation?

Infection – a small risk of infection exist at a rate of around 1 %. This is higher in diabetics or those who smoke. Most cases can be treated with antiobiotica alone. More severe cases may need surgery to remove the suture and suture anchors and perform a clear out. Often multiple operation may be needed to eradicate the infection and achieve skin cover.

Bleeding– excessive bleeding may lead to formation of congealed blood under the skin (Haematoma) this may need surgery to evacuate in rare cases.

Nerve injury or numbness– sensory nerves to the foot cross the outer ankle. Whilst care is taken to avoid injury occasionally they can be bruised or cut. This will not affect walking ability but may cause a patch of numbness on the back or outside of the foot. Sometimes a small regrowth of the nerve may lead to a painful nodule in the scar (neuroma), this may need to be surgically excised.

Thrombosis – Blood clots in the calf (Deep vein Thrombosis) can occur after lower limb surgery. These can break off and go to the lungs causing pulmonary embolism (PE). We assess individual risks of thrombosis and balance agains the side effects of blood thinning injections. You may therefore be offered injections for the first two weeks after surgery.

Complex Regional Pain Syndrome (CRPS)– this is a rare complication that can result in post op pain and skin colour changes in the whole of the foot and sometimes the entire lower leg. It occurs in less than 0.5% but can result in a poor outcome and prolonged recovery.

Recurrence or lack of benefit – the surgery is successful in over 90-95% of patients in eliminating their ankle instability. Those will lax ligaments or high arches are at increased risk of treatment failure. If recurrence occurs then revision surgery may be indicated. This may use artificial ligaments or donor tendon grafts and may also need surgery on the bones to lower the arch or realign the heel.

What is the post operative course?

Weeks 0-2

You will be in a plaster backslab and non-weightbearing with crutches.
In this time you can take the painkiller prescribed and elevate your leg as often as possible. Unless you can work from home it is recommended that you stay off work in this time.
It is important that you move around to reduce the risk of blood clots and also to exercise the rest of your muscles but don’t have your operated leg down for more than 20 mins at a time.
You will be given a follow up appointment at 2 weeks post op for cast removal and wound inspection at which point most patients will be given a “moon boot”. You can then start to weightbear on the operated foot.

Weeks 2-6

In this period you are able to walk with full weightbearing. You may wish to discard the crutches as you gain confidence.
It is also a good idea to start some gentle rehabilitation with exercises of the ankle out of the boot but taking care to avoid turning the ankle in or out.
You can start work and will manage most daily activities.
You are also able to have a shower or bath if careful and out of the boot.

Weeks 6-12
Physiotherapy will commence and you will discard the boot at the beginning of this period.
Any impact activity or sports should be avoided but gentle in-line exercises such as cycling or swimming can commence.

Week 12 onward

You can gradually begging sports. Initially in line sports such as jogging or cycling but eventually sports involving cutting and turning such as football, hockey or netball.
I do recommend that you wear a sports ankle support such as the AirCast A60 during any such sports for the first year after surgery.

 

Sick Leave
In general up to 2 weeks off work is required for sedentary employment longer periods may be necessary for more physical work.

Driving
You will be able to return to driving following the 6 weeks review, based on satisfactory progress.

These notes are intended as a guide and some of the details may vary according to your individual surgery or because of special instructions from your surgeon.

 

Further information

We recommend the following links for further information on this surgery:

Patient information leaflet from Guy’s and St. Thomas’ Hospitals NHS Trust

Information provided by the American Foot and Ankle Society