Review of Post-Operative Rehabilitation Protocols Following Ankle Lateral Collateral Ligament Repair in Adults

Special Issue: Ankle Fractures

Foot Ankle Stud. 2023; 5(1): 1028.

Review of Post-Operative Rehabilitation Protocols Following Ankle Lateral Collateral Ligament Repair in Adults

Michael Apostolides, MD, MSc, MRCS¹; Mina Mazin Al-Janabi, MBBS iBSc, MRCS²; Crispin Southgate, FRCS (T&O)³; Baljinder Singh Dhinsa, FRCSEd (T&O), MSc, MFSTEd³

¹East Sussex Healthcare NHS Trust, UK

²Princess Alexandra Hospitals NHS Trust, UK

³East Kent Hospitals University NHS Foundation Trust, UK

*Corresponding author: Michael Apostolides East Sussex Healthcare NHS Trust, The Ridge , St. Leonards-on-Sea, East Sussex, TN37 7PT, UK. Tel: +44 7473250592 Email: michael.apostolides1@nhs.net; michaelapostolides88@gmail.com

Received: July 13, 2023 Accepted: August 16, 2023 Published: August 23, 2023

Abstract

Ankle sprains are very common injuries and are usually managed non-operatively. With poor rehabilitation, 20% of ankle sprains may develop chronic instability, which often necessitates surgical intervention. Rehabilitation after such procedures is focused on regaining the function of the ankle while keeping a stable joint. Post-operative rehabilitation and weight-bearing status varies greatly among surgeons. Our aim is to review the existing most recent literature that investigates post-operative outcomes following different rehabilitation protocols in patients with Chronic Lateral Ankle Instability (CLAI).

We performed a literature search from 2002 to 2022, through Medline/Pubmed databases using the terms ‘ankle lateral ligament’, ‘repair’, ‘reconstruction’ and ‘post-operative rehabilitation’. A gray literature search was also performed using the Google Scholar search engine. Studies that described post-operative rehabilitation protocols following CLAI surgery were included.

25 studies with 1045 patients describing rehabilitation protocols following repair/reconstruction of CLAI were included. Most studies used the Broström procedure or modification of it. In 82% of cases patients were immobilised in a cast from day 1 post-operatively for two weeks and were kept non-weight-bearing in 64% during the same time. A boot or brace was kept up to 6 weeks in 82%. Full weight-bearing was recommended either at the very start following surgery (32%), or after four weeks from surgery (36%). Early range of movement exercises started after week 2, with muscle strengthening, proprioception, and balance between week 2 and 6. Return to sports is usually between 2-4 months.

In conclusion, post-operative rehabilitation protocols following CLAI surgery vary considerably. We attempted to quantify the studies that provide enough information on this subject and create a post-operative rehabilitation protocol following anatomic repair/reconstruction for CLAI.

Keywords: Chronic lateral ankle instability; Modified broström-gould; Post-operative rehabilitation

Introduction

Emergency Departments are inundated with musculoskeletal trauma, with up to 50% resulting from ligamentous injuries [1]. Amongst these, 40% involve the ankle, the lateral ankle ligamentous complex injuries being the most prevalent within the sporting community and the general population [2]. The Anterior Talofibular (ATFL) and Calcaneofibular Ligaments (CFL) are the ones that are most commonly injured [2]. Management of these ankle sprains is mostly conservative, but it is reported that, with poor rehabilitation, up to 20% can result in chronic instability [3]. This may manifest as frequent ‘giving-way’ of the ankle while weightbearing, or inability to return to sports due to the lack of objective stability, for more than 6 weeks from injury. While most acute ankle sprains can be managed conservatively, Chronic Lateral Ankle Instability (CLAI) may require operative management, when conservative measures fail [3,4].

Nonoperative management is the initial approach for treating CLAI, with physiotherapy, orthotic devices, and proprioceptive training. However, in persistent instability or failure of conservative measures for more than 3 to 6 months, operative management can be considered [5]; this includes anatomic ligament repair or reconstruction and non-anatomic reconstruction techniques [6]. The Broström technique, first described in 1966, offers anatomic repair of the ATFL and CFL, and is considered the gold standard [2]. There have been many modifications to this technique, as well as arthroscopic variants [5].

The recovery period after such procedure is between 3 and 6 months [2]. Rehabilitation protocols are essential to allow for patients to regain their range of motion in the ankle [5]. However, the optimum length of rehabilitation as well as the main concept of early versus late mobilization is still controversial [5]. Some surgeons are protective of the repair/reconstruction and keep ankles immobilized in a cast for up to 6 weeks. While this protects the repair, it can also lead to decreased ankle motion and muscle atrophy, making the overall rehabilitation process more challenging (and not conducive for a return to sports) [2]. Others allow early mobilization of the ankle, but this also comes with risks of complications, especially wound-related [2]. Confidence in the reconstruction of the ligamentous structures has improved with the use of anchors and polyethylene suture material; however the orthopaedic dogma of postoperative immobilization remains. Our aim was to perform a narrative review of the most recent literature describing postoperative rehabilitation protocols after surgical management of CLAI.

Methods

A literature search was performed via Pubmed/Medline databases using the terms ‘ankle’, ‘lateral collateral ligament’, ‘repair’, ‘reconstruction’ and ‘post-operative rehabilitation’, for studies that investigated different rehabilitation protocols in patients with CLAI from 2002 to 2022. A gray literature search was also performed using the Google Scholar search engine. We felt that a 20-year period is a good representation of the published literature on this subject, given that the number of studies published on CLAI has significantly increased since 2014. Articles included in this review were studies describing their post-operative rehabilitation protocols following CLAI surgery, comparative or case series. If the description was incomplete, or the authors failed to provide timings for the rehabilitation period, the study was excluded.

Protocols were categorized based on the type of surgery: anatomic repair or reconstruction, and non-anatomic reconstruction (Figure 1). We recorded the type and length of immobilization, weight-bearing status and type of exercises allowed with physiotherapy, including time frames, and the complications reported. We lastly looked for aim to return to work and sport. Using the evidence, we attempted to create a standardized rehabilitation protocol based on type of repair/reconstruction performed.