Arthroscopic Treatment of Ankle Ligament Injuries

Ankle Ligaments and Chronic Instability

The stability of the ankle joint is provided not only by its bony structure but also by the strong ligaments surrounding it. Three main ligaments, known as the lateral ligament complex, are particularly important for the ankle’s stability against outward (lateral) motion:

1. Anterior Talofibular Ligament (ATFL): This is the most commonly injured ligament in ankle sprains. It limits forward sliding and inward rotation of the ankle.
2. Calcaneofibular Ligament (CFL): Prevents excessive inward rotation (inversion) of the ankle. It is typically injured together with the ATFL in more severe sprains.
3. Posterior Talofibular Ligament (PTFL): This is the strongest of the three and is usually injured only in very severe trauma or ankle dislocations.

Chronic Ankle Instability (CAI): This is a recurrent feeling of “giving way,” “rolling,” or “insecurity” in the ankle that develops after one or more ankle sprains, particularly as a result of inadequate healing or elongation of the ATFL and/or CFL. Patients typically struggle when walking on uneven surfaces or during sports and frequently complain of recurrent ankle sprains.

Goal of Arthroscopic Treatment: The goal of surgical treatment is to restore ankle stability by repairing or reconstructing the lax or torn ligaments, prevent recurrent sprains, relieve pain, and allow the patient to safely return to activities.

Why Does Chronic Ankle Instability Occur?

The main cause of CAI is usually that the initial ankle sprain was severe enough that the ligaments could not heal fully, or that an appropriate rehabilitation program was not followed after the injury. Other factors that contribute to the development of CAI include:

• Inadequate Rehabilitation: If muscle strength, balance, and proprioception (the ability to sense the joint’s position) are not fully restored after the initial sprain, the risk of re-injury increases.
• Recurrent Sprains: Each new sprain further weakens the ligaments and increases instability.
• Generalized Ligamentous Laxity (Hyperlaxity): In some individuals, the ligaments are structurally more lax.
• Foot Structure: A high-arched foot (pes cavus) can make the ankle more prone to sprains.
• Muscle Weakness: Weakness of the peroneal muscles, which turn the ankle outward, cannot protect the ankle against sudden inward rotation.
• Poor Proprioception: A weak ability to sense the ankle’s position causes protective reflexes against sudden movements to be delayed.

Symptoms of Chronic Ankle Instability

• Recurrent Ankle Sprains: This is the most prominent feature. The ankle can twist even during simple activities or with only mild strain.
• A Feeling of “Giving Way” or “Insecurity” in the Ankle: The sensation that the ankle moves out of control or cannot bear weight, particularly on uneven surfaces, when going down stairs, or during sports.
• Chronic Pain and Swelling: Persistent pain and swelling on the outer side of the ankle, especially after activity.
• Restricted Motion: Some limitation of movement may occasionally be felt.
• Balance Problems: Difficulty standing on one foot.

Diagnostic Methods

A careful evaluation is required to diagnose chronic ankle instability and identify its underlying causes:

• Detailed History: Information is gathered on when and how the first sprain occurred, how many times it has recurred, in what situations the feeling of insecurity occurs, the location and character of the pain, and the sports and activity level of the patient.
• Physical Examination:
  
  • The outer side of the ankle is checked for tenderness on palpation, particularly over the ATFL and CFL.
  • The presence of swelling or deformity is assessed.
  • Joint range of motion is measured.
  • Stability Tests: These are very important for diagnosis. The integrity of the ATFL is assessed with the Anterior Drawer Test and the integrity of the CFL and ATFL is assessed with the Talar Tilt Test. These tests check for excessive laxity or forward/lateral opening of the ankle and are always compared with the healthy side.
  • The strength of the peroneal muscles and their tendons is checked.
  • Balance and proprioception are assessed.
• Imaging Methods:
  
  • X-ray: Primarily taken to rule out other problems such as fracture, bony impingement, or advanced-stage osteoarthritis. AP, lateral, and mortise views are requested. A Stress X-ray (taken while manual stress is applied) can sometimes be used to objectively demonstrate ligament laxity.
  • Magnetic Resonance Imaging (MRI): Very useful for showing in detail the condition of the ligaments (ATFL, CFL) — tears, elongation, thickening — the cartilage surfaces within the joint (particularly for osteochondral lesions (OCL) of the talar dome), the peroneal tendons, increased intra-articular fluid (synovitis), and signs of bony impingement. OCL and peroneal tendon problems are frequently seen alongside CAI.
  • Ultrasonography (US): In experienced hands, it can be used to dynamically assess the integrity of the ligaments and the peroneal tendons.

Treatment Options: The First Step is Non-Surgical Treatment

In chronic ankle instability, treatment always begins with non-surgical (conservative) methods. The goal is to achieve functional stability without the need for surgery.

• Physical Therapy and Rehabilitation: This is the cornerstone of treatment and must be applied regularly for at least 3-6 months. The program includes:
  
  • Peroneal Muscle Strengthening: These muscles, which turn the ankle outward, are very important for dynamic stability.
  • Proprioception and Balance Training: The ankle’s position sense and reflex responses are improved through exercises such as single-leg standing and balance board exercises.
  • Range-of-Motion Exercises.
  • Agility and Functional Exercises.
• Ankle Brace or Taping: Reduces the risk of re-sprain by providing extra support to the ankle, particularly during sports or risky activities. It is not curative on its own and is used alongside rehabilitation.
• Activity Modification: Avoiding risky surfaces and movements.
• Medication: NSAIDs may be used for flare-ups of pain and swelling.

Surgical Treatment: Arthroscopic Ankle Ligament Repair and Additional Procedures

If the patient’s recurrent sprains, feeling of insecurity, and pain persist despite at least 3-6 months of a regular and comprehensive conservative treatment program, surgical treatment is considered. Today, this surgery is frequently performed using the arthroscopic (minimally invasive) method.

• Ankle Arthroscopy: A thin camera (arthroscope) and special surgical instruments are inserted through 2-3 small incisions (approximately 0.5 cm) made around the ankle. This allows the surgeon to see inside the joint in magnified detail on a monitor and perform the procedure. The advantages of arthroscopy include smaller incisions, less postoperative pain, a faster recovery process, and the ability to review the entire joint and treat any accompanying problems.
• Procedures Performed During Arthroscopy:
  
  • Intra-Articular Evaluation: The cartilage surfaces (is there an OCL?), the condition of the ligaments, bony protrusions (impingement), and the synovial tissue (joint lining) are examined in detail.
  • Synovectomy / Debridement: Inflamed joint lining (synovitis) or loose cartilage/bone fragments within the joint are removed. Soft tissue or bony protrusions causing impingement can be shaved down.
  • Treatment of Accompanying Pathologies: Any osteochondral lesions (OCL) or bony impingement identified are treated arthroscopically in the same session (microfracture, cartilage debridement, bone shaving, etc.). Treating these additional problems is very important for the success of the ligament repair.
  • Arthroscopic Ligament Repair (Anatomic Repair):
    
    • Broström(-Gould) Repair: This is the most commonly performed and widely regarded gold-standard method for treating chronic instability. The worn or elongated lateral ligaments (primarily the ATFL, and the CFL if needed) are identified. These ligaments are tightened or shortened and firmly reattached anatomically to the outer ankle bone (fibula) using suture anchors (small screws/anchors placed in the bone) and the sutures attached to them. The repair is usually reinforced with the surrounding joint capsule or retinaculum tissue as well (Gould modification). This procedure can largely be performed arthroscopically.
  • Arthroscopic Ligament Reconstruction: Rarely, if the quality of the patient’s own ligament tissue is too poor for repair, or if previous repairs have failed, new ligaments may need to be created (reconstruction) using a tendon from elsewhere in the patient’s own body (autograft) or a tendon from a cadaver (allograft). This procedure can also be performed arthroscopically or with an open technique.

By preferring arthroscopic methods in the treatment of ankle instability in Ankara, Prof. Dr. Murat Bozkurt performs the ligament repair while simultaneously addressing other problems within the joint, offering his patients comprehensive treatment.

Risks, Benefits, and the Recovery Process

• Benefits (Surgery): Permanent restoration of ankle stability, elimination of recurrent sprains and the feeling of insecurity, reduction of chronic pain and swelling, improved function, a safe return to sports and activities, and treatment of other problems in the joint at the same time.
• Risks:
  
  • General surgical risks: Infection, bleeding, blood clots (DVT — rare in the ankle), and anesthesia risks.
  • Specific risks: Superficial nerve damage (superficial peroneal nerve or sural nerve), which can cause numbness, tingling, or excessive sensitivity on the top or outer side of the foot. This is usually temporary but can rarely be permanent. This risk is lower with the arthroscopic method. Other risks include joint stiffness, persistent pain or instability, and failure of the repair.
• Recovery Process: Rehabilitation is important after arthroscopic ligament repair.
  
  • Immobilization: To allow the repaired ligaments to heal, the ankle is typically immobilized after surgery for several weeks (e.g., 2-6 weeks) using a cast, splint, or special walking boot, and full weight-bearing on the leg is usually avoided during this time (crutches are used).
  • Physical Therapy: This begins after immobilization and lasts for months. The program includes:
    
    • Exercises to regain range of motion.
    • Strengthening the peroneal muscles (very important!).
    • Intensive balance and proprioception exercises.
    • Gait training and functional exercises.
    • Specific exercises for return to sport.
  • Timeline: Return to normal daily activities can take a few weeks to a few months. Return to more demanding activities such as running and sports typically takes 3 to 6 months or longer after surgery. Full compliance with the rehabilitation program is critical for a successful outcome.

Arthroscopic Ankle Ligament Treatment in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Chronic ankle instability is a condition frequently encountered in Ankara, particularly among active individuals and athletes, and it reduces quality of life. In his approach to this problem, Prof. Dr. Murat Bozkurt:

• Detailed Diagnostic Evaluation: Fully determines the degree of instability and particularly any accompanying intra-articular problems (cartilage damage, impingement, etc.) through the patient’s history, a careful physical examination, and imaging such as MRI.
• Priority on Conservative Treatment: Ensures that an effective physical therapy and rehabilitation program is tried for a sufficient period (at least 3-6 months) before making a surgical decision.
• Minimally Invasive Surgical Approach: When surgery is required, he prefers arthroscopic methods, which provide less pain, better cosmetic results, and potentially faster recovery.
• Comprehensive Treatment: During arthroscopy, he not only performs the ligament repair (usually the anatomic Broström technique) but also treats all identified intra-articular pathologies (OCL, impingement, etc.) in the same session, offering a holistic solution to the problem.
• Focus on Rehabilitation: He knows that the key to postoperative success is good rehabilitation and closely follows up with his patients throughout this process.

Chronic ankle instability is a condition that reduces quality of life and, if left untreated, can lead to permanent joint damage. When non-surgical treatments fail, arthroscopic ligament repair offers an effective and reliable solution. With this method, it is important not only to repair the ligament but also to address other problems within the joint. For your ankle problems in Ankara, you can benefit from the expertise of Prof. Dr. Murat Bozkurt.

For detailed information and appointments, you can contact Prof. Dr. Murat Bozkurt at 0312 502 70 74.