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Chronic ankle sprains are a problem that plagues many individuals. Once the ligaments of the ankle have been compromised, they are subject to repeat injury. A person with chronic ankle sprains will often report an initial injury, possibly one that was never treated. There is usually constant swelling and pain at the ankle, and a feeling of instability, as if the ankle might give out at any time.
Chronic ankle instability can develop from damage to the nerve endings in the ligaments responsible for proprioception. Proprioception is the body’s ability to know where a particular part lies in space. Repetitive or chronic injury to the ankle ligaments can damage the proprioceptors in the ankle, leading to that feeling of instability. A person with chronic ankle injuries may also have attenuated, stretched out, and weakened ligaments, particularly of the lateral ankle.
Most commonly, the ligament that is damaged is the anterior talo-fibular ligament, or the ATFL. The calcaneofibular ligament (CFL) or posterior talo-fibular ligament (PTFL) may also be involved, as well as the extensor retinaculum, peroneal tendons, or the joints in the area such as the calcaneocuboid, tarso-metatarsal joints, subtalar joint, or the ankle joint itself. In high ankle sprains, the tibiofibular syndesmosis may also be injured.
Conservative care for chronic ankle injury revolves around protecting the ankle with high-top shoes or braces. These devices may work well in some individuals, but fail to offer enough support in others. In particular, high-performance athletes may be candidates for surgical repair of the ligaments if and when conservative therapy fails.
Surgery for lateral ankle instability focuses on reconstructing the lateral ankle and adding stability to the joint. There are a number of different techniques to do this. Most frequently, cases of chronic ankle instability are due to injury of the ATFL, or a combination of the ATFL and CFL. Depending on the extent of the injury, various procedures may serve to reconstruct and/or repair these ligaments.
Several procedures exist that use the peroneus brevis tendon, the extensor retinaculum, or both to reconstruct the ATFL and/or the CFL. These procedures may involve drilling a small hole in the tip of the fibula or the talus, and re-routing the tendon through the holes. When done correctly, this can add significant stability to the ankle joint.
Another technique involves using soft tissue from another part of the body, such as the tensor fascia lata in the hip and thigh, as a graft to reconstruct the ligaments. Cadaveric grafts or synthetic materials may also be used.
Many variables play into the decision-making of the surgeon and patient. The goals of the patient and the surgeon should be clearly communicated, as well as possible complications of the surgery and shortfalls that may exist. Lateral ankle reconstruction may not be an option for some patients, such as those with systemic conditions that may complicate the surgery or postpone healing. A thorough discussion should be had with a foot and ankle surgeon to assess the situation.
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