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    Old 05-24-2006, 04:57 AM   #1
    jprinz99
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    Question ankle instability and surgery?

    Can anyone offer any wisdom for me? I have chronic ankle instability (broke ankle 3 times and sprained over 30 since I was young, now 37). I have been quite active in competitive sports my whole life up to about 2 years ago. I had to slow down as the feet were acting up.

    First week of March I twisted my left ankle walking, lunged to the right and screwed up the right ankle pretty good. I fell/landed wrong - broke my ankle (os trigonum/sheperds fracture and cracked one other bone) and trashed my lateral ligaments, possible tendon tear/strain.

    Cast for 1 month, then a boot for a month. Now in a Don-Joy lace up brace with crossing straps (1 month so far).

    Been in PT since 1 week after cast came off. Ankle is very wobbly, rolls frequently (even in brace). Poor proprioception/balance, thus I am falling and covered in bruises.

    I go back to ortho doc again on 6/5. Expect to hear I will need either Brostrom or Chrisman-Snook surgery. Not quite sure what to expect. Have read up on it and it sounds like a bear.

    Anyone had this done and results? How long is rehab afterwards? Are you happy or not. How easy is it to blow out a Brostrom/ why would you choose one procedure over another?

    Getting pretty fed up with this foot right now and am finally ready to get it fixed once and for all. Thanks a lot for your input!

     
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    Old 05-24-2006, 09:52 AM   #2
    MFord1206
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    Re: ankle instability and surgery?

    I had a modified brostrom with arthroscopic debridement in March of 2005. I had broken the ankle and tore the ligaments in April 2004. The break healed, the ligaments did not. I tried PT to help strengthen the ankle back up and to regain proprioception, but it didn't help. The instability was affecting my day-to-day life. I couldn't walk without twisting the ankle. It began to become very painful, and I had daily swelling in the ankle.

    So, decided to have the surgery to correct the problem. Surgery wasn't all that bad. I was in a post-op splint for 2 weeks, then a fiberglass cast for 2 more weeks, non weight bearing. Then into an aircast boot, and started PT. I was in PT for about 6 weeks before my strength was back to 80% of normal. The ankle is very stable now, and I have not twisted it once since the surgery. Overall, I think I made the right decision to have to surgery.

    If you have any more questions, please don't hesitate to ask!

    Good luck!

    Megan

     
    Old 05-24-2006, 11:07 AM   #3
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    Re: ankle instability and surgery?

    I had a straight Brostrom Repair August 2003. I was 3 weeks NWB, 8 weeks PWB in a CAM Walker, followed by PT. I haven't had any issues with rolling the ankle since then, and believe me, there have been plenty of opportunities. See what your OS says regarding the two different procedures, I don't know much about the Chrisman-Snook procedure, it may depend on what condition your tendon is in as to which procedure you end up with.

    Good luck! -eko
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    Old 05-24-2006, 12:00 PM   #4
    jprinz99
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    Re: ankle instability and surgery?

    Thanks -

    This sort of good news is just what I wanted to hear! Funny, I thought I was the only one who was having a rough time in PT and falling over...

    Again, thanks for your input!

     
    Old 05-24-2006, 05:14 PM   #5
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    Re: ankle instability and surgery?

    Megan, EKO, other veterans of ankle repairs, esp. those who've had bone and ligament issues... I'm Kim, you've plodded through some of my ignorance in other threads, and know I had distal fib fx, medial and anterior, lateral / collateral damage. 1st OS referred because he didn't want to do bone alone, and 2nd wanted to do bone alone, didn't want to do ligaments. Now, healing from osteotomy, I'm finally given the admission that "there is still space in the mortise, probably because you tore and stretched ligaments, and it will likely slop around". This, and the associated pain, (even in a cast, nwb, I'm aware of the anterior compartment, and seem to have my pf tightened to boot), is unacceptable. Whether he works up a plan, or I find another OS, it simply won't work.
    Knowing I will be faced with decisions to attempt repairs or fuse, and regretful that I didn't know you were here or have any other source for educating myself before the deed was done, I'm reading.
    Would you please describe these procedures? And if you were bone and ligament, the order your repairs were done, if it makes any difference to the outcome? Thank you, JPrinze, for opening topic. I wish you luck in your repairs, whichever route you go. kim

     
    Old 05-25-2006, 07:57 AM   #6
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    Re: ankle instability and surgery?

    Has your OS done stress views of the ankle? I have a similar situation, and we just did stress views a couple of weeks ago. They were very telling and my doc is pretty conservative, so I am on "serious rehab" as he calls it, a MUCH sturdier brace, and no surgery. I too roll my ankle, but I have a lot of specialists in my life who are anti-surgery, and tell me that it just takes a lot of time and strength training to get an ankle not to roll. I have a different point of view from surgery, so I'd love to know whar stress views said. What my OS says is that surgery is good in the sense that the ankle won't roll, but the ankle is esentially, like wood. You don't have the proprioception or ROM to make the minute changes needed when you mistep unsteadily. The ankle won't roll, he says, but you'll just topple over and fall. It's an interesting perspective, isn't it?

     
    Old 05-25-2006, 11:10 AM   #7
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    Re: ankle instability and surgery?

    I feel like I was the queen of ankle instability problems a few years ago when I broke my ankle and tore the lateral ligaments. I was very active with all sorts of sports and when I returned to sports, I found that my ankle felt wobbly and like it was going to collapse. My surgeon said that the fibula healed well but my ligaments were stretched out (confirmed with stress xray). After failed attempts to strengthen the ankle with pt, I had the Brostom repair but unfortunately, my ligaments stretched out again after a year! My surgeon said this had never happened to him before. So I had the more aggressive repair where they take a tendon and drill through the ankle and the results were great (although the recovery was aweful).
    It turns out that I have hyperlaxity of my tendons and ligaments and that is why the original repair stretched out. If you are spraining your ankle that often, I would get the repair. If you have extreme flexibility like myself, you might want to think about the Chrisman-Snook. Good luck!

     
    Old 05-25-2006, 02:15 PM   #8
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    Re: ankle instability and surgery?

    Karyn, It IS interesting. When you said you had a similar situation, were you speaking to JPrinze, or me? I'm not sure if you had a bone repair and your OS didn't want to mess with your ligaments? How long have you been at the pt? Have you noted any changes? Especially if you feel positive, but either way, please tell me how you feel about your chances with pt. I'm not against this, will milk every last drop out of pt when my time comes, I just have this sinking in my gut that I "shoulda" fused. I planned to have one op only, but have felt it was a mistake. He didn't do a full weightbearing view, as I'm nwb still. My first OS did them, those and the MRI are why he said I needed more help than he could give, as he didn't do ankle joint ligaments at all. Current OS did a dorsiflexed view, to simulate weightbearing, and there was still space where there shouldn't be, though it was less than in the original shot. It is my understanding, and anyone correct me if I'm wrong, please, that these puppies tend to tighten and contract during periods of disuse, and loosen and stretch during use? So the idea that this "might" improve in pt, I shouldn't hold my breath?

    Diane, how long out of the Chrisman-Snook are you? Will you describe the difference between the 2 procedures, and what your experiences were, pain, nwb time, pwb time, pt? Are you as active as you wish, or do you find you're limited in any way? Thank you!

     
    Old 05-25-2006, 03:23 PM   #9
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    Re: ankle instability and surgery?

    Here is a little bit about the Brostrom Repair...
    What is it?

    The Brostrom operation is a repair of damaged ligaments on the outer ("lateral") side of the ankle.

    Why would it be done?

    If you have torn the ligaments on the lateral side of your ankle and the ankle keeps giving way on you, you would normally be prescribed a course of physiotherapy to settle down inflammation in your ankle, strengthen the muscles on the outside of your ankle(peroneal muscles) to help control the joint better and re-teach the nerve endings inside the ankle to work better. This improves the problem and allows most people to get back to activities. If it does not, we would then suggest an exploratory operation on your ankle to assess the damage and see if there is anything extra wrong inside the ankle joint itself. This operation is called an "arthroscopy" of the ankle.

    If the arthroscopy confirms that your ankle is truly unstable and there is nothing else the matter, but you continue to have problems, you would have the choice between wearing a lightweight brace on the ankle while doing the things that cause your ankle to give way, or having an operation to repair the damage. If you

    are very big or heavy
    play high-impact sports such as rugby
    have weak muscles in your leg
    have problems with the joint in your heel (the "subtalar" joint")

    you would be best to have the torn ligament replaced with a piece of tendon (the "Chrisman Snook" procedure). If none of these apply to you, and especially if you play sports which are low or medium impact such as jogging or tennis, we would recommend a simple repair of the ligament. This is the Brostrom operation.

    What does it involve?

    A cut is made over the outer side of the ankle. The remains of the ligament are found. Small grooves are made in the bone on the outer sde of the ankle (the "lateral malleolus"). Small screws are placed in the bone and stitches attached to these screws are used to fasten the ligaments back in place. The tissues on the outer side of the ankle are than stitched to the ligament to support it. The skin is closed, usually with a dissolving stitch buried under the skin. A plaster is applied to the leg.

    Occasionally the ligament is so badly damaged, or the ends are so scarred, that it cannot be repaired. In that case, the ligament would be replaced with a piece of tendon from the outside of your ankle. The tendon used is the "peroneus brevis" which runs down the back of the ankle on the outer side and over the outer side of the heel, helping to pull the foot upwards and out. Only half the tendon is used - the other half is left attached and can do the work of the whole tendon. The cut for this is longer and a second cut may be needed higher up the leg to get the tendon free. The free piece of tendon is attached to the bone with stitches tied through small screws in the bones where your ligaments normally run. The skin is closed, usually with a dissolving stitch buried under the skin. A plaster is applied to the leg.

    It is not usual to have to change from a Brostrom operation to a tendon operation, but it cannot always be predicted and you should be prepared for the possibility. The main difference is that a tendon operation may be "tighter" and a little stiffer, and in the long term the ankle may ache more. However, it is a very strong repair.
    *****
    Hope this helps a little, there is a lot of info on the "net."

    -eko
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    Old 05-25-2006, 05:06 PM   #10
    jprinz99
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    Re: ankle instability and surgery?

    Thanks for the feedback you guys - keep it coming!

    So here are some other thoughts... I am really putting forth an effort in PT, but have only made some minor gains. Seem to have gotten as good as it gets. I can stand (with feet apart a fair bit, weight mainly on left (good)leg, have better ROM than when first out of cast and boot (duh), muscles are getting stonger.) Balance still screwed up, very bad foot placement especially backwards, still aches and/or hurts, swells and gets "tired" where it just quits. PT and I do a lot of three legged, three footed walking as he helps hold me up or mat work (standing, step forward and back, close your eyes etc) but he has to have a hold of me 100% since I fall and sway all over the place. I am not even this close to my husband half the time -ha ha. I feel like a fool and look pretty silly too. PT wears me out mentally and physically, and I end up having to use the crutches to get to the car (then I am useless the rest of the night)

    As for surgery - PT thinks I need either a Chrisman-Snook ot triple arthrodesis. He doesn't think the Brostrom will do me much good, nor will it last. He said I will probably blow it out in either a typical sports move or a seizure (I have uncontrolled epilepsy). Anyone had this failure of a Brostrom?

    By the way, when yours rolled how did it physical look. My outer edge of foot (toes to heel) cranks over on its side, outwards, and often the top right side of foot will be on the carpet. My fibula gets to about 1/2" off the floor, at best. It doesn't hurt like it used to with a roll. I guess it is so stretched out it is now used to rolling. Don't get me wrong, it hurts but doesn't leave me on the floor crying in agony.

    My PT told me we would be spending some "Quality Time" together no matter what surgery I have (he and other PT's are 100% about need for surgery, but are taking actual bets as to which procedure!! It's up to 75 bucks! ha ha Any clues as to how long and how bad it is?
    He said if it were him he would go for either the fusion or try the Chrisman-Snook. Now I know he isn't a MD, but he is a pretty sharp tack and an athlete who also has taken care of a lot of ankles, so I trust him to tell it like it is, if you know what I mean. He said I have the worst ankle he has seen (gee, there's something tobe known for, eh?)


    How long are you normally in a cast, etc - it seems to be across the board, but the Brostrom repairs seem to get up on their feet the soonest - yes/no?
    Will my balance also be fixed by surgery or is this a permanent thing? Is it tough to walk, run, jump etc after a repair (any type) and how much could you get back into, sports and regular life wise. I can't even go out and about without the big boot. I only last a short while, as it hurts and swells. Using the brace in public is a no go, as I fall down a lot and make a spectacle of myself, and store managers always come running (think I either hurt myself or am drunk).

    I just feel like I can't trust this foot and am tired of being held back. I have never felt so handicapped and angry/frustrated. My husband is getting pretty fed up and his patience is wearing away also. He wants it fixed and now. I am also tired of hearing from friends, etc things like "You still having problems? Mine was better in 6 weeks" This feels like the longest 10 days (till my appointment) - ever. I am 3 months post injury and have never been this bad so long afterwards.

    Any suggestions or thoughts on how to approach my OS doc about getting it fixed? Just trying more rehab is not going to work. I don't want him to think I am a hypochondriac or surgery nut - I just am ready to scream "glue it, fuse it or cut it off". I want this done and over with once and for all, I want to be normal.

    Sorry so dramatic and so long winded- just needed to dump on those who have "Been there, done that and got the Tshirt" Thanks a million!

     
    Old 05-25-2006, 09:26 PM   #11
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    Re: ankle instability and surgery?

    EKO,
    Thank you so much. I appreciate you taking the time to be thorough and detailed. I wish you were my OS, or would teach him how to communicate!
    I don't believe that either of those corrections would be appropriate, think my problems are medial. I do have thickening/edema in the lateral collaterals, but do not roll. They provide lateral stability? So they are likely not loose. My OS did not remark on them. He was surprised, remarked he'd cut through a lot of scar tissue to get to the fibula.
    The fx (oblique) shortened the fib about 3/4 cm, leaving space in the mortise. Pre-op, the whole thing slopped back and forth, rubbing bone and stretching ligaments. I only did this for 4 months and change before I went for help, so if there was tearing, it was healed prior to the mri. Post-op, I would expect less, but won't know until I walk. There is more space than he wants, but only walking will say if its too much.
    The areas I'm aware of from pain experience and MRI results are the deltoids, (Right? Those are on the medial?), anterior tibfib and lateral collaterals, with thickening and edema.
    When the initial cast came off, he pronounced me stable and I returned to work. The worst pain immediately was medial and anterior. I have a high threshold, but it was so bad I went to my PCP first, sure I had DVT. She referred me back to OS. He thought the ligs were my problem, not bone. His partner and a foot/ankle man in SPFD thought the bone and the ligs needed repair. His partner wanted to do arthroscopic explore and debride, but "remembered" at the last minute that I was someone else's patient and sent me back. It was during this time, while going without support so the skin would heal that the lateral bone pain recurred.
    As the corrections you described are for the lateral, I will try to do some research online to find corrective measures more specific to my issues. If anyone else on this board has had this trouble, please post your experiences.
    Again, EKO, thank you for taking the time. Kim

     
    Old 05-25-2006, 09:45 PM   #12
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    Re: ankle instability and surgery?

    JPrinze,
    I'm sorry you can't seem to get it over with, I understand the feelings. I told my OS I wish he'd cut the stupid thing off already. I think your PT is right about your best options being the Chrisman-Snook or maybe a fusion, but discuss it with your OS and get another opinion, before you commit. It is a big decision.
    The ligament repairs do have shorter recovery times, and others here would have to tell you how successful they were. I think there is a thread from long ago, search maybe 3 months, or further, from someone who'd blown a Brostrum, but I don't know how.
    Fusion takes longer, and is irreversible, and causes mobility problems, but, when it works, resolves instability and pain. Do you want mobility? The ability to continue in activities unrestricted? Probably ligament repair. Do you mind the knowledge that you "might" have to return later for further repairs or fusion? If not, probably repair.
    If you need/want a one-shot fix, and can deal with losing ROM, you might look at fusion. I know active people are willing to do anything to have no restrictions, some to the point of 10+ surgeries. I wanted only one, and regret not choosing fusion. If I can walk without pain I will walk, and bike, etc., for exercise. I don't need anything more, and I'm too old to choose a career of surgeries.
    You did well to ask here, there are many with lots of knowledge to share. Keep posting, and let us know how you are. Kim

     
    Old 05-26-2006, 07:14 AM   #13
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    Re: ankle instability and surgery?

    I understand how frustrating it can be,waiting and wanting a solution now, been there and done that. One thing you should do is decide what do you want to achieve when all is said and done beside being pain-free and mobile. Do you want to be able to run, or just walk, wear high heels, dance, what do you want to do when all is said and done? Have you gotten a second opinion? Don't be afraid to lay it on the line with your doctor(s).

    Good luck and if I can be of additional help, please let me know. -eko
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    Old 05-26-2006, 09:49 AM   #14
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    Re: Brostom vs. Chrisman Snook

    Jprinz,

    When my surgeon first decided to do the Brostrom repair to tighten the lateral ligaments I had torn, I told him I was very active and played tennis and did figure skating as well. Now, this was a few years ago- 1997- and he didnt offer me any other procedures. When I finished recovering from this surgery, I felt like my ankle was tight and stable for about a year, and then I started feeling like it was giving way again. My surgeon said he couldnt believe it, but I had stretched out his repair! He said this normally doesnt happen, but he decided to do the Chrisman-Snook (although he didnt tell me the name) which involved taking a piece of my hamstring tendon and using it to stablilize the ankle in place of the lat. ligaments.
    I have to say that the recovery was very difficult- in terms of pain- but I dont think this is typical. Again, my ankle felt great (if not overly tight) and I had full rom. About a year later, after I had returned to skating and tennis, I again complained of instability. My os said there was nothing more he could do for me and I went to another os. He did an MRI and it showed a torn Posterial Tibial Tendon. I have NO idea when this happened or if it was a result of the surgery. This led me down the road of a fusion which eliminated the problem of instability but also eliminated any side to side motion of my foot. I gave up the sports which I loved but I no longer had problems with pain or instability. The fusion is a big procedure (especially a triple fusion) and it can cause problems with stress on other joints. I dont mean to make this decision more difficult, but I hope this information helps!

     
    Old 05-26-2006, 09:54 AM   #15
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    Re: Brostom vs. Chrisman Snook

    Oh, I forgot if I told you I have hyperlaxity of my tendons and ligaments (just meaning Im very flexible) and my os feels this is why I stretched out the Brostom repair. Not sure if this helps, but I just thought I would let you know about this factor.

     
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