Recurrent ankle sprains, pain, and chronic instability are conditions we treat on a regular basis. There are many treatment options as these conditions are quite common and the degree of instability can vary widely. When conservative measures have failed, surgery can provide relief for the vast majority of patients.
A variety of procedures have been utilized to address ankle instability. Historically, direct repair of the ligament (sewing the ligament back together) resulted in reasonable outcomes but was certainly not without its drawbacks. Old injuries often meant that there was little remaining ligament or substantial soft tissue to sew back together. This made tensioning and a robust repair problematic. Re-injury and tearing of the repair was extremely common.
The advancement of bone anchors was a great step forward in terms of repairing ankle instability. A bone anchor is an implant used to secure soft tissues back to bone. These anchors are usually constructed of metal, bio-absorbable materials, or other advanced medical grade plastics. They’re typically screwed or press-fit into drill holes and provide excellent security/strength in good bone. Attached to the anchor are strong sutures which are utilized to secure the torn ligament back to the face of the bone. The development of quality bone anchors has resulted in significant improvement and patient outcomes and made for a simpler more reproducible procedure. Unfortunately, re-injury and tearing of the repairs remained extremely common especially if the soft tissues were compromised. Unfortunately with chronic injuries, this is often the case.
Tendon transfers and grafts have also been utilized to reconstruct ligaments with some success. These procedures usually resulted in more a substantial and robust repair that were difficult to re-injure. The downside was more extensive surgery and harvesting of what would be an otherwise healthy, functional tendon and transferring it to provide ligamentous support where needed. This was often well-tolerated but certainly less than ideal.
More recently, a new anchor system called an “internal brace” has been utilized to address many of the shortcomings of the above procedures (the internal brace is a product made by Arthrex, a company with which we have no affiliation). This technique is utilized in conjunction with one of the above procedures as augmentation. The main problem with less invasive techniques has always been re-injury and compromise of the repair. The internal brace is placed on top of the repair as reinforcement. This utilizes a strong fiber tape placed over the repaired ligament that is secured on either end directly to the talus and fibula bones to bolster the ligament repair and serve as a backup. Another way to look at it is the primary ligament repair provides dynamic stability where the internal brace is more of a static construct which serves as a secondary backup if the primary repair were to loosen or become torn. This greatly lessens the detrimental impact of weak soft tissues with regard to the overall structural integrity of the repaired ligaments. In our experience this has been a nice adjunctive procedure and has improved outcomes, particularly over the long-term.