EUA, Ankle Arthroscopy and Lateral Ligament Reconstruction Modified Brostrum-Gould Procedure

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1 Secretary Susan Rse Cnsultant Orthpaedic Surgen The Oaks Hspital /3254 EUA, Ankle Arthrscpy and Lateral Ligament Recnstructin Mdified Brstrum-Guld Prcedure 1 Examinatin Under Anaesthetic (EUA) invlves examining the ankle whilst yu are asleep. We put it thrugh a range f tests yu might nt tlerate awake. The purpse is t cnfirm signs f ligament damage (Instability). It is ften dne under xray. **Please infrm us if there is any chance yu culd be pregnant Ankle arthrscpy is a keyhle surgical technique that allws us t lk inside and see the surfaces f the ankle jint and prceed t sme treatments there and then. It invlves the insertin f a 3-5mm camera int the ankle alng with varius micrinstruments. Varius treatments are described later. Lateral Ligament Recnstructin f the ankle invlves pen surgery t the uter side f yur ankle. The damaged ligament/s are then deliberately cut befre being gathered / reefed up, versewn and anchred dwn t recnstruct their functin. The prcedure was riginally described by Surgens Brstrum & Guld. We nw use sme mdern ~2.5mm metal pegs t anchr the repair t the bne, thus mdifying this further. This technique is designed t imprve the stability f yur ankle. It is nt used t help a stable but painful ankle. Arthrscpy & its Treatment prcedures. Diagnstic Arthrscpy Once the scpe is in the jint it is inspected and any damage and areas f nrmal are usually phtgraphed fr keeping in yur medical ntes. This diagnstic prcedure can be just as imprtant as any subsequent treatment fr the infrmatin it prvides. Debridement & Synvectmy: This ccurs in ver 90% cases and invlves the shaving and remval f scar, synvitis r lse tissue that is felt t be symptm related. Synvitis is inflamed sft tissue that appears like seaweed attached t structures and when entrapped can cause pain. It is very variable whether the synvitis is the cause f the prblem r a painful result f anther mre mechanical issue. Either way, shaving it away can ften make a very psitive difference t pain and swelling. Remving this tissue als allws us t see int the jint mre easily imprving the accuracy and ease f further prcedures. Specialist Ft & Ankle Surgen Clchester

2 Secretary Susan Rse Cnsultant Orthpaedic Surgen The Oaks Hspital / Cheilectmy: This is the technical name fr grinding r Burring away prminent and abnrmal ridges f bne (Ostephytes). These prminences have usually resulted in impingement pain whereby mvement is painfully limited as ppsing ridges f bne pinch each ther during mvement. (see picture) Occasinally pieces f these extra bne can break ff and becme lse bdies within the jint which can als be remved. If they are large then larger scars can be required t achieve this. Ostechndral Defect (OCD) management: OCD s are islated patches f damage t the surface cartilage f the jint and underlying bne. They can vary in size frm a few millimetres but can be pstage stamp size r larger. They appear either as flaps f cartilage expsing the bare bne underneath r as patches f sft unstable cartilage with underlying damaged bne. In effect they are a small discrete patch f severe arthritis. Very ccasinally a prtin f bne is still attached t the flap. (See picture belw) Lse cartilage cannt be stabilised r repaired. It is cleared back t the gd adherent, stable cartilage leaving the discrete patch f expsed bne underneath. If left this wuld nt just heal s is treated with micrfracture. Micrfracture :- The tp layer f bne is brken thrugh t stimulate the bleeding f stem cells int the defect. The principle f this is much like the healing f skin cut A scab cartilage frms that after a perid f time frms Scar cartilage. Like thse n the skin they never lk quite the same but will usually functin in much the same way. The restratin f a stable scar cartilage prvides satisfactin with pain relief in up t 85-90% f cases. (See Vide!! Bny prminences resulting in impingement. lifted by metal prbe Unstable cartilage flap Specialist Ft & Ankle Surgen Clchester

3 Secretary Susan Rse Cnsultant Orthpaedic Surgen The Oaks Hspital /3254 The Lateral Ligament Recnstructin (Mdified Brstrum-Guld) 3 A curved incisin abut 5cm lng is made directly ver the ligaments n the uter side f yur ankle. Lcal nerves are lked fr and held ut f the way. There are tw main parts t the ligament that are dealt with:- ATFL (Anterir TibiFibular Ligament) CFL (CalcaneFibular Ligament). The PTFL can me managed withut surgery and hence is nt addressed Mdified Brstrum - The damaged ligament cmplex is expsed and then deliberately cut. The tw free ends are gathered up and ver each ther and tied tgether thus reefing up the ligament. This is augmented by anchring dwn the recnstructed ligament t the fibula bne with 2-3 small metal pegs (Suture Anchrs) Guld A nearby thin layer f tissue (Extensr Retinaculum) is dissected ut and drawn up and ver the Brstrum repair as an extra layer f supprt. What shuld I expect? This is perfrmed as a Daycase prcedure under a General anaesthetic unless there are medical reasns t avid this. It takes abut 1.5 hurs t d. Experience has shwn patients leaving the hspital abut 4-6 hurs after their surgery. Yu will wake up with a plaster cast (Backslab) put n belw the knee leaving just the Tes expsed. Yu will g hme prtecting yurself against a Thrmbsis (DVT, Deep Vein Thrmbsis, Bld Clt, Emblism) Wearing a Stcking (TED) n the ther leg Specialist Ft & Ankle Surgen Clchester

4 Secretary Susan Rse Cnsultant Orthpaedic Surgen The Oaks Hspital / Having an injectin r tablet every night t thin yu re bld a little whilst yu are in a plaster cast Wiggling yur tes and mving yur knee & Hip t keep circulatin ging Ensuring yu stay hydrated whilst at rest. Will it hurt? After the peratin yur ankle shuld be cmfrtable as lcal anaesthetic will be used in the peratin scars. This will wear ff after 6-8 hrs. Yu will then need painkillers. Tablets shuld be sufficient but take them regularly fr 24-48hrs as the surgery pain settles. Yur ankle will swell up initially. This is nrmal. Yu must try t minimise it hwever by resting with yur ft elevated Tes Abve Yur Nse Reclined in bed r n a sfa with yur ft n pillws As a guide it shuld be elevated fr 45-50minutes f each hur ver the 1 st tw weeks. Occasinally yu may have sme sreness r even bruising in yur thigh where we have used the tight turniquet fr yur peratin. This pain will usually settle. What d I d with the dressings The dressings and Cast shuld be left alne. If yu ntice any significant lsening r bleeding then cntact the hspital Will I have stitches Yes. As a standard we use an absrbable suture (Vicryl rapide) that disappears in time and shuld be left alne. Can I Walk On it Afterwards? NO - Yu shuld nly tuch yur tes dwn fr balance whilst yu are in the plaster cast. Try t imagine resting yur te n a snail but nt crushing its shell At 2 weeks yu will receive a plastic, Velcr strapped bt (Aircast / Beckham Bt). Frm then n yu will be able t walk full weightbearing as cmfrt allws. Specialist Ft & Ankle Surgen Clchester

5 Secretary Susan Rse Cnsultant Orthpaedic Surgen The Oaks Hspital / At 6 weeks yu will wean ut f the bt in t a brace and nrmal ftwear with the physitherapists Belw Knee ½ plaster cast Aircast type bt Aircast type ankle brace 0-2 weeks 2-6 weeks frm 6 weeks In the cast yu shuld nt mve the ankle. Once yu are in the bt yu will receive specific instructins frm the physitherapists with regards t ankle mvement exercises. The bt is t be wrn during the day whilst active and whilst in bed at night. It can be remved at rest, whilst bathing and fr rehab. Exercises. What is the rehabilitatin ging t invlve? The physitherapy rehabilitatin f these prcedures is all imprtant and adherence t the instructins given during the pathway even mre s. The team will regularly treat and assess yur prgress after the surgery fr 3-6 mnths. This will be lead by the physi team and they will meet and explain everything alng yur rehabilitatin jurney. 0-6 weeks are a Recvery phase during which the main principle is t allw the wunds, stitches and ligaments t heal. This means prtecting the ankle whilst trying t maintain range f mtin and muscle functin weeks yu will enter the Rehabilitatin prgram with the Physis. This invlves weaning ut f a small stirrup brace and wrking n ankle stability exercises much like thse undertaken befre the surgery. This lasts fr 3-6 mnths t achieve the full result. It is sensible t cntinue with these arund sprts especially lifelng. A cpy f the physi rehab prgram is available upn request. Specialist Ft & Ankle Surgen Clchester

6 Secretary Susan Rse Cnsultant Orthpaedic Surgen The Oaks Hspital / Will I be seen again after the surgery? At 2 weeks :- Yu will have an appintment t check the wunds are healing. Yu will then cnvert frm the Cast t the Bt. At ~6 weeks:- Yu will have an appintment t assess prgress with respect t surgery pain and t cnsider prgressin frm recvery t rehabilitatin. The exact nature f this depends n the individual surgery dne. Yu will receive an ankle brace frm the physitherapists. At ~3 mnths:- Yu will be seen t assess the n-ging rehabilitatin f the surgery and lk t yur expected utcme. This will cmmnly be yur final planned appintment. What are the risks f this Surgery? Bleeding - This is rarely prfuse and settles with elevatin and bandaging. Shuld yu see Bld dripping frm the wund r saking the cast please seek medical attentin Infectin Any incisin thrugh the skin carries this risk and it is lked fr specifically at the 2 week check utpatient appintment. A skin infectin will usually settle with tablet antibitics but a jint r bne infectin, thugh extremely rare is very serius and can result in disability and cmprmise f the surgical result. Nerve damage The incisins pass very near nerves which are held ut f the way. They can respnd even t this handling with sme temprary tingling r numbness that will settle. Rarely a neurma / accidental injury can cause lnger term nerve symptms with lss f sensatin in the ft r a mre cmplex pain reactin. Tendn damage Whilst keyhle the incisins int the ankle pass very near tendns and ccasinally these can be damaged causing pain and extremely rarely subsequent rupture. Yu wuld experience this as a weakness f ankle mvement s Specialist Ft & Ankle Surgen Clchester

7 Secretary Susan Rse Cnsultant Orthpaedic Surgen The Oaks Hspital / alert this t the team if nticed. Shuld a rupture happen yu may require recnstructive tendn surgery t crrect it. Recurrent pains Arthrscpy has its limits and ccasinally the damage prgresses and becmes increasing symptmatic with time. As yet we have n cure fr general jint arthritis / damage. Dissatisfactin The evidence t date has shwn an verall satisfactin with the varius indicatins frm 65-90% with this surgery. It is designed t imprve the situatin. The ligament surgery hwever has a much mre like 90-95% success rate f achieving stability. This drps ff thugh in peple with generalised ligamentus laxity. Thrmbsis - Fllwing ankle surgery and particularly whilst yu are in a plaster cast yu are at increased risk f develping a bld clt (Thrmbsis /DVT / Pulmnary Emblism) in yur legs. T mitigate against this yu shuld Stay hydrated, wiggle yur tes, mve yur knee and use a TED stcking n the ther leg. Yu will als receive a curse f injectins (Clexane/Enxaparin) t thin yur bld slightly during the perid yu spend in plaster cast.. **Any calf cramp like pain that desn t reslve r acute chest pain/shrtness f breath and yu shuld seek medical attentin urgently as this culd represent a thrmbsis.** Stiffness During the stabilisatin yur ligament is deliberately tightened up and this creates initial stiffness. This will usually reslve with the rehabilitatin but ccasinally can persist lng term. Re-rupture The scar tissue ligament that frms fllwing the surgery is likely t always be a little weaker than the ne yu were brn with. If stressed again t much it culd re-rupture. Metalwrk prblems - During the arthrscpy instruments very rarely break and the ankle then needs t be pened up t retrieve sme bits. Als the small suture pegs (Anchrs) used can ccasinally cause prblems by being prminent r becming infected / lse. This culd mean failure r further surgery What are the alternatives? This type f functinal prblem is nt a cancer r life threatening and therefre we will nt be instructing yu t have it dne, s t speak. It is abut imprving yur functinal quality f life. There are always therefre alternatives:- Specialist Ft & Ankle Surgen Clchester

8 Secretary Susan Rse Cnsultant Orthpaedic Surgen The Oaks Hspital / Accept and wrk with the disability 2. Cntinued physitherapy and use ankle splints r painkillers 3. A mre cmplex recnstructin using tendn graft dnated by yur wn ankle/knee. (e.g Chrisman-Snk). This is usually reserved fr revisin cases. Specialist Ft & Ankle Surgen Clchester