Operative indications and cases to be wary of

A lateral ankle ligament reconstruction is indicated if non operative rehabilitation has failed to address ankle instability

The ankle should be demonstrated to be laterally unstable upon examination.If apparently normal whilst the patient is awake then examination should be repeated as the first stage of the operation ,under image intensifier screening. A difference is sought with the normal side. If no difference is present then functional instability rather than mechanical instability is present and the cause of instability lies with pathology within the joint. (Very) rarely this does not hold true and despite the joint being mechanically stable to examine it is not stabilised by treating the intra-articular pathology. The problem here is presumably proprioceptive and these rare cases are sucessfully revised using the lateral ankle ligament reconstruction.

Pain per se is not a symptom of ankle instability , other than transient pain directly following on from an acute episode of instability. Pain independent from episodes of ankle instability will be due to intra-articular pathology (synovitis, chondral /osteochondral defects, plica). A pre-operative MRI is performed to confirm or rule out an osteochondral defect. A theraputic arthroscopy should preceed the lateral ligament reconstruction.

In a patient with ligamentous hypermobility an augmented reconstruction should be used instead (either using Graft jacket or peroneus brevis re-routing). The same augmented techniques should be used for stabilising an ankle replacement and considered for revision instability cases.