Emerging options available to treat chronic ankle injuries

Douglas Goforth
Douglas Goforth

Ankle pain, instability and stiffness rank among some of the most common ailments. I’d like to share some insights regarding chronic ankle injuries and pain as well as information about emerging treatment options.

The ankle has a unique anatomy.  The joint functions differently from other joints of the body and responds to treatments differently.

When the cartilage of any joint wears out or becomes damaged, the result is progressive arthritis. The most common causes of this type of damage vary from joint to joint. While knee arthritis is frequently the result of wear and tear, ankle arthritis is almost always the result of an old injury.

An ankle sprain or fracture that fails to properly heal results in altered function. This is sufficient to cause arthritis. Instability isn’t compatible with the tight tolerances the ankle requires to stay healthy. The result is accelerated wearing of the cartilage and worsening, more frequent pain. This usually occurs over a number of years following the initial injury, but also can begin at the time of injury.

Immediately after an acute ankle injury, good care can often prevent the need for more invasive treatments later. When an injury to the stabilizing ligaments of the ankle fails to properly heal, chronic instability can occur. At this stage, periodic bracing, supportive shoes, insoles and physical therapy are often adequate.

When conservative measures have failed, surgery offers a solution for the majority of the remaining patients. Athletes and active people often find the instability becomes a significant limitation, affecting their return to sports and other activities. Surgical intervention is a great option for people whose ankle instability alters their lifestyles. Restoration and tightening of the torn ligaments combined with arthroscopy (scoping of the joint to remove inflamed synovium) results in good outcomes for active patients. The goal is to permanently restore ankle function and stability and halt ankle arthritis.

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 to bone. These anchors are usually constructed of metal; bioabsorbable materials; or other advanced, medical grade plastics. They’re typically screwed or press-fit into drill holes and provide security and strength in good bone. Attached to the anchor are strong sutures that secure the torn ligament 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 procedures. Unfortunately, reinjury and tearing of the repair remains a consistent but somewhat less common complication if the soft tissues were compromised. With chronic injuries, this is often the case.

More recently, suture tape and bone anchors have been combined to augment traditional repairs. This creates an internal brace effect. This technique is used in conjunction with other procedures. The main problem with less invasive techniques has always been reinjury and compromise of the repair. The internal brace augmentation is placed on top of the primary repair as reinforcement. This uses a strong fiber tape placed over the repaired ligament that’s 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, the primary ligament repair provides dynamic stability, while the internal brace constitutes more of a static construct that 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 in regard to the overall structural integrity of the repaired ligaments. In my experience, this has been a nice adjunctive procedure and improves outcomes, particularly over the long-term.