Ankle > Ankle Sprain > Treatments

   Open Ligament Reconstruction

Treatment Introduction

Surgery to reconstruct ligaments after an ankle sprain is usually performed after you have tried conservative treatment, have gone to physical therapy and have good ankle strength, but continue to have signs of instability in your ankle. Repeated ankle sprains is an important sign of ankle instability that may need surgical treatment. Competitive athletes and other people who need to be on their feet may become candidates for surgery immediately after suffering a severe, Grade III sprain that hinders their ability to walk. Though surgery is commonly prescribed to treat torn ligaments, partially torn or elongated ankle ligaments can cause a chronically unstable ankle that may benefit from surgery.

Preparing for Surgery

The actions you take before surgery can be every bit as important as the procedure itself in ensuring a healthy recovery.

   Prior to your return home from the hospital, make sure that you have received any equipment you will need when you get home. This may include crutches or household items to make movement around the house easier. You should receive prescriptions for any of these from your doctor before you go home from the hospital.

   Any physical problems or changes in your overall health, such as a fever or infection, should be reported to your surgeon, and you should notify your surgeon of any new medications you are taking.

   If possible, discontinue the use of any anti¡Vinflammatory medicine, especially aspirin, a week prior to surgery, to prevent excessive bleeding during the procedure.

   To reduce the risk of infection, improve healing, and decrease complications, try to quit smoking or decrease the amount you smoke. In general, smokers have a higher infection and complication rate overall.

   To learn about the potential risks and benefits of the surgery, ask your surgeon any questions that will help you better understand the procedure. It can also help to talk to someone else who has undergone the same surgery.

   Getting a second opinion from another qualified surgeon is often advisable, particularly in rare or unique cases.

   To check if the orthopedist performing the surgery is board-certified or eligible, call the American Board of Orthopaedic Surgery at 919-929-7103.

   What to ask the doctor

   What to take to the hospital

Day of Surgery

At most medical centers, you will go to "patient admissions" to check in for your operation. There may be separate check-in areas for ambulatory outpatient (patients go home the same day after surgery) and for overnight inpatient surgery, so be sure to ask your doctor or an assistant about this. After you have checked in to the hospital, you will go to a holding area where the final preparations are made. The mandatory paperwork is completed, and your ankle may be shaved, though this is not always necessary. You will be asked to change into a hospital gown and, if applicable, remove your watch, glasses, dentures, and jewelry. You will have the opportunity to speak with your orthopedic surgeon or an assistant and meet the anesthesiologist or nurse anesthetist (a nurse who has done graduate training to provide anesthesia under the supervision of an anesthesiologist). An IV (intravenous) line may be inserted into your arm at this time. Then, you will walk or ride on a stretcher to the operating room. Most patients are not sedated until they go into the operating room. Here are some important steps to remember for the day of your surgery:

   You will probably be told not to eat or drink anything after midnight on the night before your surgery. This will reduce the risk of vomiting while you are under general anesthesia.

   Since you will most likely be able to go home within a few hours of surgery, arrange for someone to drive you home when you are released.

   Wear a loose pair of shorts, sweatpants, or other clothing that will fit comfortably over your short leg cast or splint when you leave the hospital.

   Take it easy. Keeping a good frame of mind can help ease any nerves or anxiety about undergoing surgery. Distractions such as reading, watching television, chatting with visitors, or talking on the telephone can also help.

   ABC’s of anesthesia

   What to take to the hospital

Surgery Procedure

Open ligament reconstruction of your ankle sprain can take about an hour to perform, depending on the extent of ligament damage. Spinal anesthesia typically is given to numb you from the waist down, and you usually are sedated so you sleep through the procedure.

   A small, four- to five-centimeter incision is made along the outside of your ankle so your surgeon can expose your fibula and heel bone.

   The two ligaments most commonly in need of repair after a sprain, called the anterior talofibular and calcanealfibular ligaments, may need to be sewn back onto your smaller lower leg bone.

   Incisions in your skin are closed with stitches and your ankle is put into a splint to immobilize it. You are then taken to the recovery room.

Recovery Room

After surgical ligament reconstruction in your ankle, you will be transported to the recovery room where you will be closely observed for one to two hours while the immediate effects of anesthesia wear off. Your ankle will be elevated and immobilized in a splint or cast when you wake up. After surgery, you typically experience some pain, and adequate pain medications will be prescribed for you. You will be given intravenous (IV), oral, or intramuscular pain medications as needed. Your temperature, blood pressure, and heartbeat will be monitored by a nurse who, with the help of your physician, will determine when you can prepare to go home. You will normally be able to leave the hospital or clinic the same day after surgery. Some patients may be admitted for an overnight hospital stay, depending on how much pain management you need. Your surgeon will prescribe crutches and you are usually instructed to keep weight off your ankle for the first three weeks. Make sure to have someone available to drive you home, as you will be unable to drive a car.

Physicians generally recommend that you avoid bearing weight until your incision has healed. Crutches may be prescribed for about three weeks after surgery. Rest as much as possible with your ankle elevated above the level of your heart. This helps blood drain away from your ankle and controls swelling. You may need to use pain medication prescribed by your physician for one or two days after surgery. Pain usually decreases within a few days. It can be helpful to have someone around the house who can assist with any physical chores. Though individual recoveries vary, a typical recovery schedule after surgery may go as follows:

   Ten days - Return to your physician's office to have your stitches removed and the post-surgery ankle splint replaced by a short leg cast. Continue using crutches to keep your body weight off your ankle while wearing the cast.

   Three weeks - Your ankle comes out of the cast and you begin weight bearing while wearing a brace called a cam walker. You may be able to discontinue using crutches, depending on how much pain you are still experiencing. You usually can perform range of motion exercises three times a day to begin rehabilitation.

   Six weeks - Most patients can stop wearing a cam walker and return to normal shoe wear. Your physician may prescribe an ankle brace that fits inside your shoes.

   Six months - Your ankle usually is back at full strength and no longer in need of a brace.

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Physical therapy usually is prescribed to help ligaments heal after open ligament reconstruction surgery. When your cast comes off three weeks after surgery, your physician may refer you to a physical therapist to begin early motion, which helps circulate fluid out of the ankle. Early motion consists of simple up and down flexion and extension, and progresses to small circles or drawing the alphabet on the floor with your toes. Therapists also may use electrical stimulation to control swelling. Physicians generally recommend that you avoid bearing weight and walking in pain after surgery. Patients tend to heal better in the long-term if they start rehab slowly, instead of rushing to begin painful exercises on an ankle that has not yet healed. When swelling and pain have gone away and you feel comfortable without supportive wrapping, you usually start an exercise program to strengthen all the muscles around your ankle. Elastic bands are often used to provide resistance as you move your ankle in different directions. You may help your ankle feel better by icing it for ten minutes both before and after rehab exercises. It is particularly important to strengthen the peroneal muscles, located on the outside of your lower leg around your small lower leg bone (fibula). The peroneals help keep your ankle from turning inward. Arthritis is a result of repeated ankle sprains, which can hinder your ability to return to your previous activity level. People with arthritis may need to spend extra time in rehab and perform a more elaborate training program. The final steps of rehab help increase coordination, and may include balance beam exercises and running in a figure-eight pattern. When the injured ankle is about 90 to 100 percent as strong as the uninjured ankle, you may be ready to begin returning to activities. Most patients can rehabilitate their ankles with four to six months of physical therapy and return to activities at full strength.

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Prevention

To prevent the recurrence of ankle sprains, you should make the stretching and strengthening you learned in physical therapy part of your regular exercise routine. A strong and flexible ankle may be more able to withstand any abnormal positions and strain that occur during sports and activities. The goal of surgery is to restore stability to your ankle. If you suffer another ankle sprain after surgery you should visit your physician because the ligament repair may be inadequate for your level of activity. Depending on your age and ankle strength, your physician may place some restrictions on your sports and activities. Before activities, remember to warm up your ankle muscles by stretching in all directions. Tight ankle muscles and ligaments may be more apt to pull or tear. Replace athletic shoes when the padding or the tread wears out. Avoid participating in activities in old, worn-out shoes because they do not provide good padding or side-to-side support.

In general, you should try to provide extra support to your ankle for at least 12 months after a severe sprain, possibly longer. Taping is a good preventive measure if it is done immediately before participating in the sport and if the person doing the taping is trained in proper techniques. Ankles are usually taped all the way from the midfoot to the lower calf. Braces may be useful after surgery to enhance recovery and prevent further injury. Neoprene sleeves provide compression, while other lace-up types of braces provide more support using metal or plastic strips on the sides of your ankle.

DEALING WITH PAIN

A small amount of pain is normal during activities, but if you feel so much pain in your ankle to warrant taking a painkiller before an activity, you should visit your physician. Do not continue to run on a sore ankle. Pain after rehabilitation could be a sign that you have other minor foot and ankle injuries that need proper treatment before you can return to activities.