Dislocation, Sprain and Strain of the Joints and Ligaments of Upper Ankle and Foot: Operative Therapy

Surgical treatment is usually not necessary.

Outer Wall Injuries

For external ligament injuries of the upper ankle joint (OSG), conservative therapy (immobilization; external stabilization if necessary; early functional follow-up) remains the gold standard! In the inflammatory phase (see below; the first day 10 days after trauma), consistent application of the PECH rule:

• “P” break: stop playing sports, rest, immobilization.
• “E” ice/cooling: immediate application of cold, this is crucial for the healing process: it prevents the expansion of tissue damage; cold also has a pain-relieving effectNotes on implementation: repeat every 2 to 3 hours; do not apply ice directly to the skin; do not use on open wounds.
• “C” Compression e.g. elastic pressure bandage (moderate tension).
• “H” Elevation above the level of the heart: reduce blood supply to the damaged tissue; better removal of tissue fluidNotes on implementation: In case of extensive swelling, elevate for 1-2 days.

External stabilization: indicated in patients with grade I or grade II injury (see below Symptoms-Complaints/Classification of an external ligament lesion using clinical features). An elastocompressive bandage/elastic socks or a semirigid orthosis (orthopedic device to relieve and immobilize the affected joints) is used; in grade III injuries, external stabilization is only possible after prior immobilization until swelling has subsided. Patients can thus quickly walk or climb stairs normally again.

Conservative therapy now also includes proprioception training, which trains perception and responsiveness, as well as self-reflex training.Surgical therapy is only justified if conservative therapy fails and in the case of additive pathologies such as cartilage or tendon lesions. The therapy of choice for the treatment of chronic instability is arthroscopy. In this regard, the following procedures are used to restore stability:

• “Thermal shrinking” or the “capsular shrinkage” (= thermal ablation; whereby with the help of electrocautery the lateral capsule and ligamentous remnants are coagulated.
• Direct ligament suture; this assumes that enough of the original ligament structure is still present.
• Tenodesis of the peroneal-brevis tendon (surgical relocation of a tendon followed by anchorage in bone)
• “Ligament bracing”: serves to stabilize the lateral ligamentous apparatus and represents an anatomical, direct reconstruction
• Augmentation: a procedure what is necessary in about 20% of patients, because a direct ligament suture is no longer possible. Augmentation is performed with tendons (preferably gracilis tendon) or allgrafts (i.e., the transplanted tissue does not come from the recipient himself, but from a (except in identical twins) genetically non-identical donor of the same species).

The main indication for OSG prosthesis is post-traumatic osteoarthritis and chronic ligament instability. Rehabilitation has to be based on the healing phases of the ligaments. Patients with early functional treatment return to sports or work earlier.After reduction of swelling and pain, the focus is on improving mobility. This is followed by targeted strength training with the patient sitting or lying down. As soon as the upper ankle joint can be loaded again, i.e. strength exercises can be performed without pain, proprioception and balance training is performed.A return to sports in high-risk sports (e.g. basketball, soccer and volleyball) that involve a change of direction is usually possible after 8 to 10 weeks. Ankle support with a brace is recommended for patients who participate in regular sports.

Dislocations

Surgical reconstruction of the ligaments and musculature may be indicated for habitual dislocations. A habitual dislocation is one that recurs during physiologic movements without additional force. Arthrodesis (stiffening) of the bones may be indicated for luxations of the tarsal/midfoot bones. Healing of the ligaments in the following 3 phases: