Right and left lateral tibiotarsal instability
A 50 years old male with generalized ligamentous laxity and long history of distortions (Sprains) of the ankles. On the right ankle the incidence and severity of the sprains had increased significantly in recent months. On MRI imaging of both ankles: in the right ankle the lateral stabilizing ligaments are damaged and incongruent. On the left ankle the picture is similar with an old fracture of the tip of the medial malleolus which is not united, but not significantly displaced. Right ankle instability was diagnosed and “Brodstrum“ type operation on right ankle has been suggested.
1) Do you confirm the diagnosis? Any further medical tests to carry out?
2) Do you agree with the surgical operation recommended by the orthopedist? What are the possible risks of this surgical operation?
3) If a surgical operation is not carried out, are there any alternative systems to reduce or to eliminate the problem?
4) After the surgical operation do you think that a certain degree of invalidity is going to remain?
50 years old, male.
The patient has always suffered from ligamentous laxity so much that since he was a child, he was subject to periodic ankle distortions. In the last period these distortions increased so much that he was forced to contact an orthopedic specialist in foot and ankle surgery. The patient carried out the specialist examination with the following medical report:
“The patient reports distortion traumas to the right and left ankle. Recent distortion trauma to the right ankle. He reports swelling in the ankle, insecurity in walking and pain. From a clinical point of view one foot is substantially in axis. Unstable at the load on the right limb. The motor activity of the peroneus muscles is good. Anterior drawer test +++. Lateral drawer test +++. The tilt test shows instability of talus bone into varus position.
It is recommended:
• Surgical correction of plastic ligament of the anterior astragalar peroneal ligament according to Brodstrum modified right tibiotarsal.
In the meantime:
• Green clay: Application in the evening for 60-90 minutes for 10 days, then when needed.
• Pennsaid drops: 15 drops locally 3 times a day for 15 days, then when needed.
• Neoprene ankle band with velcro reinforcements, type FGP DTX 09 or CV3 500.
In addition, it was advised to carry out the right and left tibiotarsal NMR that the patient performed, with the following medical report:
“On the right, slight articular effusion in tibiotarsal area, in particular at the posterior recess level. Normal the morphology and the signal of the articular heads with preserved articular ratio and regular thickness of the covering cartilage in the tibio-astragalic area. The anterior astragalar peroneal ligament is badly definable in particular in the distal portion with appearance of tear result being recognizable the proximal segment of the ligament itself -
Regular the morphology and the posterior astragalar peroneal ligament and the deltoid ligament signals, while also the peroneal-calcaneal appears dishomogeneous, less distinct, not recognizable in all its elements. Minimum liquid effusion layer of inflammatory appearance in the sheath of the peroneal tendons, without dislocation aspects. On the left, still slight articular effusion in tibiotarsal area and result of detachment of bone fragments recognizable near the apex of the peroneal malleolus and of the internal tibial malleolus. The fibers of the anterior astragalar peroneal ligament are badly definable, still recognizable only in the proximal segment as a tear result and also the fibers of the peroneal-calcaneal ligament are very badly definable with the same nature. Substantially normal the appearance of the posterior astragalar peroneal ligament and of the fascicles of the deltoid ligament.
Normal the appearance of flexor and extensor muscles without effusion in the sheath.”
A 50 years old male with generalized ligamentous laxity and long history of distortions (Sprains) of the ankles. On the right ankle the incidence and severity of the sprains had increased significantly in recent months.
From the clinical description provided for the right ankle he suffers from significant rt. ankle instability. On MRI imaging of both ankles: in the right ankle the lateral stabilizing ligaments are damaged and incongruent (both anterior talo fibular and calcaneal fibular ligaments). The cartilage and the tendons around the ankle are normal. On the left ankle the picture is similar with an old fracture of the tip of the medial malleolus which is not united, but not significantly displaced.
The patient was examined by specialist in foot and ankle surgery that recommended an operation to stabilize the ankle. A “Brodstrum“ type operation has been suggested.
Ankle instability can be a significant disability. The diagnosis is more clinically than by imaging. In this case the history and the described clinical signs for the right ankle with the imaging provided is very suggestive of significant lateral instability on the right ankle. I prefer prior to surgery to get also X-Rays in stress, to demonstrate the instability, either with: stress inversion on AP or TELUS stress device, and compare between the 2 ankles.
The “Brodstrum“ procedure is a well documented procedure and gives very good stability. In my practice it is the “first line“ procedure to re-stabilize an unstable ankle. It gives very good functional results. The risks are as with any operation: post operative infection, prolonged post operative pain and failure to achieve functional stability. However according to the medical literature and my personal experience these are very rare complications.
Until the ankle is stabilized it is recommended to use a dynamic ankle brace (air cast-sport, exoform, sweedo or any other good functional brace). Physiotherapy, especially to work on proprioception.
If surgery is preferred to be avoided, a very intensive rehabilitation program is to be initiated and protection by a dynamic ankle brace to be used in sport is advised. It should be tried for 3-4 months. If the functional outcome is insufficient I recommend to have surgery.
After the operation, a period of immobilization is required (3-6 weeks) and then rehabilitation for 3-6 months is needed until returning to full activity including sports. If everything goes well – returning to full activity with no invalidity should be expected.