Not all ankle instability is “simple” or just a consequence of lateral ligament incompetence / insufficiency. When there are multiple contributing factors at play, the situation is referred to as “complex” and a multi-pronged approach to surgical management is often required.
In general terms, muscle weakness and malalignment(deformity) are the other issues which can require attention.
The peroneal muscles, with their tendons, are important and essential dynamic stabilisers of the ankle. As pathology affecting the peroneal tendons is frequently associated with instability, particularly when it is long-standing, it often needs to be addressed at the same time as a ligament reconstruction. This usually consists of splitting and tearing of the tendons, which results in pain, swelling and weakness. Split tears can be repaired, sometimes with the transfer of a healthy adjacent tendon to strengthen a diseased one. This will have the effect of restoring dynamic stability to the joint.
A varus (turned in) heel, in association with a high arch, can contribute to instability and require bony procedures, in combination with a soft tissue reconstruction, in order to cure instability and prevent a recurrence of giving way. When this foot structure is present, bones can be osteotomised (cut) and moved into a new position to correct alignment. Buried screws or plates are normally used to secure the new position whilst bone healing occurs. Sometimes, if the pattern of deformity is severe, or if there is accompanying joint stiffness or arthritis, a realignment can be combined with an arthrodesis (fusion) of the affected joint. In the case of hindfoot deformity this is typically the subtalar joint.
If a tendon reconstruction is required, six post-operative weeks of strict ankle splintage and non-weight-bearing is needed before the commencement of physiotherapy treatment.
If a joint fusion is needed, a further two weeks of the same is required.