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Ankle injuries can occur to anyone and limit your mobility.  Despite elevation and rest does your ankle pain and swelling persist?  What are ankle ligaments?   How serious is a ligament tear?   What is Brostrom ankle surgery?   What are the risks of Brostrom ankle surgery?  Is there a safe, effective nonsurgical treatment for ankle ligament injuries?   Let’s dig in.

Ankle Ligaments

Ligaments are the thick connective bands of connective tissue that connect one bone to bone.  They provide important stability to the joint.   The ankle has ligaments both on the inside (medial) and on the outside (lateral) part of the joint.  The ankle ligaments most commonly injured are those on the outside.  Injuries occur from trauma such a rolling your ankle. The incidence of ankle sprains is between two and seven per 1,000 people and ankle sprains account for approximately 30% of all sports-related injuries (1).  There are three important ankle ligaments on the outside of the ankle that provide stabilize the joint.

  • Anterior talofibular ligament (ATF)
  • Calcaneal fibular ligament (CF)
  • Posterior talofibular ligament (PTF)

The names of each ligament refer to the bones they attach to.  For example, AT ligament is the ligament that connects the fibula bone to the talus bone.  The ankle is susceptible to injury including strains and tears.  Damaged ligaments can lead to ankle instability which if left untreated is a BIG deal.  Chronic ankle instability puts the joint at risk for significant injuries which include arthritis, tendon and ligament tears and ruptures,

How Serious Is a Ligament Tear?

It depends upon the severity of the tear.  There are three types of ankle ligament tears:

  • Partial-thickness ( the tear only involves a portion of the ligament)
  • Full-thickness (tear involves entire ligament but the ligament is still intact)
  • Full-thickness with retractions (tear involves entire ligament and the two edges are pulled apart).

If you have sustained a full-thickness tear with retractions, surgery is your only option.  Fortunately, a large number of ankle ligament injuries are only partial-thickness or full-thickness tears without retractions.  These patients can likely avoid ankle ligament surgery.

What Is Brostrom Ankle Surgery?

Brostrom ankle surgery is a reconstruction of one or more lateral ankle ligaments.  The goal is to repair the loose lateral ligaments. The surgery is performed under a general anesthetic or spinal block and takes 1-2 hours.  The torn ligament or ligaments are surgically removed and replaced with either cadaver, or a patient’s own, tendons.  The tendons serve as the “new” ligaments.  The surgery involves drilling holes into the bones and lacing the tendons through the holes to take the place of the damaged ligaments (2).

What Are the Risks of Brostrom Ankle Surgery?

Surgical complications include bleeding, infection, nerve damage, and surgical failure. In one study the complication rate was 29% and involved wound healing, nerve injuries, blood clots, complex regional pain syndrome (3).  Another important complication is recurrent instability (4) which puts the ankle at risk for additional injury, degeneration, and arthritis. In a recent study, 31% of patients who underwent Brostrom ankle surgery still had ligament laxity (4).

How Long Does It Take to Recovery from Brostrom Ankle Surgery

Ankle surgery is not for the faint of heart.  The recovery is extensive and first starts with crutches followed by walking boot. Outcomes vary on study design, patient demographics and metrics being evaluated. In one recent study, athletes who only had ankle ligaments tears returned to training at 9 weeks on average after lateral ankle reconstruction (5).  Return to sports was longer at 11 weeks on average.  Return to training was prolonged to an average of 12 weeks and return to sports 15 weeks when an additional injury was present

Is Ankle Reconstruction Surgery Painful?

The short answer is yes as the damaged ligaments are removed, holes are drilled into the bones and tendons are harvested from different body sites.  Then there are the crutches followed by walking boot and extensive physical therapy.

Ankle Ligament Surgery Alternative

A novel nonsurgical treatment option is now available for the treatment of partial and full-thickness ankle ligament tears.  The procedure is called a Percutaneous Ankle Ligamentoplasty (PAL).  It involves precise, ultrasound-guided injections of a patient’s own bone marrow concentrate into the damaged ligaments.  Stem cells can heal ligament tears in two principal ways (6).

  • Turn into (differentiate) ligament cells
  • Recruit other repair cells in the body to come and assist.

Ligaments that have a partial-thickness or full-thickness tears can be successfully treated with precise ultrasound-guided injections of bone marrow concentrate.  Seeing is believing.  At the Centeno-Schultz Clinic, we started using bone marrow concentrate to treat ankle ligament injuries over a decade ago.  Below are ankle MRIs before and after bone marrow concentrate treatment at our clinic.  On the left, the red circle identifies the anterior talofibular ligament (ATF) which is loose and is bowing in nature.  The MRI on the right is after precise ultrasound-guided injections of bone marrow concentrate.  The yellow circle identifies the complete healing of the ATF ligament after the PAL treatment.

The procedure is challenging and can not be performed by your PCP or orthopedic surgeon.  To watch an ultrasound-guided ankle injection please clinic on the video below.

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Ankle ligaments are not the only injuries successfully treated with a precise injection of bone marrow concentrate.  At the Centeno -Schultz Clinic we pioneered the treatment of Anterior Cruciate Ligaments (ACL) tears with bone marrow concentrate. The ACL is a critical ligament in the knee that provides stability.  We published two peer-reviewed articles on successful nonsurgical treatment of ACL tear and are awaiting the third publication later this year (7) (8).  Below is an MRI  of one of my patients prior to and after precise injection of bone marrow concentrate into the ACL. The ACL is identified by the dashed yellow lines.  On the left, the ACL fibers are loose, wavy and poorly organized.  The MRI on the right is after treatment and now the ACL is tight and well organized.

 

In Conclusion

Ligaments are the thick connective bands of connective tissue that connect one bone to bone. There are three important ankle ligaments on the outside of the ankle that provide stabilize the joint.  Brostrom ankle surgery is a reconstruction of one or more lateral ankle ligaments.  Tendons taken from other locations in the body or cadaveric are used to create the new ankle ligaments.   Recovery involves crutches, followed by walking boot and extensive physical therapy.  A new ultrasound-guided procedure where bone marrow concentrate is injected into the damaged ligaments is an effective nonsurgical treatment option for lateral ankle ligament tears.  Reasons to avoid Brostrom ankle surgery include.

  • Ripping out a partially torn or loose ligament makes no sense when your body’s own repair cells’ function is to repair.
  • Your surgically relocated tendon or that of a cadaver will not function as well as your own ligament.
  • Drilling holes in bones and  lacing your tendon  to create a new ligament does not ensure that your ankle will be stable
  • Surgery is associated with complications which include injection, failure, nerve damage, and ligament laxity
  • Ankle ligament surgery involves significant pain, recovery, and rehabilitation

The PAL procedure, a precise injection of bone marrow concentrate into damaged ligaments is a safe, effective nonsurgical alternative to Brostrom ankle surgery that does not require extensive rehabilitation or have the surgical risks.

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1.Guillo S, Bauer T, Lee JW, Takao M, Kong SW, Stone JW, Pearce CJ. Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy. Orthoped Traumatol Surg Res. 2013; 99(8):S411–S419.DOI: 10.1016/j.otsr.2013.10.009.

2.Shakked RJ, Karnovsky S, Drakos MC. Operative treatment of lateral ligament instability. Curr Rev Musculoskelet Med. 2017;10(1):113-21..doi: 10.1007/s12178-017-9391-x

3.Corte-Real NM, Moreira RM. Arthroscopic repair of chronic lateral ankle instability. Foot Ankle Int. 2009;30(3):213-7. DOI: 10.3113/FAI.2009.0213.

4. Messer TM, Cummins CA, Ahn J, Kelikian AS. Outcome of the modified Broström procedure for chronic lateral ankle instability using suture anchors. Foot Ankle Int. 2000;21(12):996-1003.DOI: 10.1177/107110070002101203.

5. Barbari SG, Brevig K, Egge T. Reconstruction of the lateral ligamentous structures of the ankle with a modified Watson-Jones procedure. Foot Ankle. 1987;7(6):362-8. DOI: 10.1177/107110078700700614.

5.Yasui Y, Murawski CD, Wollstein A, Kennedy JG. Reoperation rates following ankle ligament procedures performed with and without concomitant arthroscopic procedures. Knee Surg Sports Traumatol Arthrosc. 2017 Jun;25(6):1908-1915. doi: 10.1007/s00167-016-4207-x.

6. Ramdass B, Koka PS. Ligament and tendon repair through regeneration using mesenchymal stem cells. Curr Stem Cell Res Ther. 2015;10(1):84-8. https://www.ncbi.nlm.nih.gov/pubmed/25274564

7.Centeno CJ, Pitts J, Al-Sayegh H, Freeman MD. Anterior cruciate ligament tears treated with percutaneous injection of autologous bone marrow nucleated cells: a case series. J Pain Res. 2015;8:437-47.DOI: 10.2147/JPR.S86244.

8.Centeno C, Markle J, Dodson E, et al. Symptomatic anterior cruciate ligament tears treated with percutaneous injection of autologous bone marrow concentrate and platelet products: a non-controlled registry study. J Transl Med. 2018;16(1):246.DOI: 10.1186/s12967-018-1623-3.

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