Ankle Instability by Mark Blackney

Blog post by Mr. Mark Blackney

Introduction

Ankle sprains are one of the most common sporting injuries. Usually the injury recovers with suitable rest and physiotherapy.

Ankle instability occurs when the ankle repeatedly gives way during sporting or even daily activities. This leads to recurrent ankle sprains, joint pain, swelling, inflammation and damage to the ligaments around the ankle. Some people experience ankle pain intermittently, others feel that their ankle ‘aches’ more often. Recurrent instability episodes can cause damage to the joint surface cartilage, the formation of bony spurs (osteophytes) and arthritis.

Non Operative Treatment

The first line of treatment for ankle sprains is rest, ice, compression and elevation with painkillers and anti–inflammatories (if tolerated). Physiotherapy is then useful to regain range of movement, strength, balance and joint position sense.

An ankle brace may be useful for people who have tried all these measures and experience ongoing problems with sporting or daily activities. Finally, a targeted corticosteroid injection may offer relief from ankle inflammation and help settle symptoms so that physiotherapy can continue.

Operative Treatment

When all these non operative measures fail and recurrent ankle instability becomes an ongoing problem surgery is indicated. The ankle ligaments are assessed clinically and an MRI scan is sometimes necessary to identify any problems within the ankle joint itself or the tendons and ligaments around the joint.

There are two components to the surgery.

An arthroscopy is performed with a camera through two small incisions at the front of the ankle. The joint surfaces are inspected, inflammatory and scar tissue is removed and any bony spurs (osteophytes) are trimmed away. An incision is made over the outside of the ankle where the ligaments have been torn away and the ligaments are reconstructed in an anatomical fashion and reinforced with overlying tissue (modified Brostrum-Gould repair). If indicated, the tendons behind the ankle are inspected and repaired.

At the end of the operation a backslab (half plaster) is applied to immobilise the ankle and protect the reconstruction.

Postoperative Recovery

As with all reconstructive surgery your rehabilitation and postoperative physiotherapy regime forms a vital part of your recovery from surgery and return to normal activities.

The first two weeks are dedicated to reducing the swelling with elevation of the foot and mobilising non–weight bearing with crutches to allow the wounds to heal. You will then be allowed to wear a lace up ankle brace and gradually increase your weight bearing status and work on range of motion. 6 weeks after surgery the brace is removed for daily activities and an intensive strengthening and balance program begins. The brace is to be worn for all sporting activities and you should be able to return to sports 3–6 months after surgery. The ankle may always be a bit stiffer than the normal side and a slight reduction in range of motion is not uncommon but this is rarely a significant problem.

Risks and complications

No surgery is risk free. The risks and complications will be assessed and discussed with you. There is always a small risk of infection, blood clots and anaesthetic problems and measures are taken to reduce these. There is approximately a 5% chance of experiencing problems with recurrent instability and this is usually due to a fresh injury or sprain. A successful outcome is achieved in more than 90% of cases.

Recovery

  • Hospital stay: 1 night

  • Elevation: 1 week

  • Plaster back slab (Non weight bearing): 2 weeks

  • Sutures removed: 2 weeks

  • Crutches: 2–4 weeks

  • Walking well: 6 months

  • Return to sports: 3–6 months

  • Final Result: 12 months

These timeframes should be used as a guide only and may vary for individual patients based on the nature or extent of the actual surgery performed and individual circumstances. Please contact Mark Blackney's rooms on (03) 9417 0762 or Terence Chin's rooms on (03) 9928 6450 if you require further information.

MEDICATIONS AND SURGERY

Blog post by Mr. Robert Howells

What medications need to be ceased before a surgical procedure?

This is a very common question that crops up before surgery. Medications that increase the possibility of complications such as bleeding or infection or thrombosis ideally need to be ceased prior to undertaking surgical procedures. Frequently these medications are taken for important medical conditions and as such, at times, consultation between your treating surgeon and the prescriber of the medication (GP or physician) will need to take place. This is to devise a plan for how and when the medication should be ceased and whether any covering medication is required and importantly when medication needs to be recommenced after surgery and how this will take place.

Blood Thinning Agents

The issue with these drugs is their ability to increase surgical blood loss. This is clearly important in major open cases such as joint replacement surgery, where blood loss can be significant and ongoing loss after surgery can occur if normal clotting mechanisms are impaired. Bleeding can even be a problem in minimally invasive surgery such as arthroscopy. Usually the joint is filled with a clear fluid (normal saline) which provides clear and easy vision to allow the arthroscopic procedure to take place. Bleeding inside the joint (and particularly bleeding that is difficult to control) creates a “tomato soup” effect rather than a clear visual field. If this is bad and can’t be cleared, the procedure may need to be abandoned.

A. Aspirin and Anti-Inflammatory Drugs

Common medications leading to blood thinning include aspirin and non steroidal anti-inflammatory drugs (NSAID). Examples are Astrix, Cardiprin (aspirin) and Voltaren, Naprosyn, Nurofen, Mobic and Celebrex (NSAID). These affect platelets and their function for about a week. It is recommended that these agents are stopped 7 – 10 days before surgery.

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B. Platelet Aggregation Inhibitors

More powerful anti-clotting agents like clopidogrel affect platelets also but their effect is longer lasting than for aspirin/NSAIDs and it is recommended that these agents are stopped at least 14 days prior to a surgical procedure. Examples include Plavix and Iscover.

These agents are often prescribed in patients with coronary artery stents in the first 12 months after insertion to prevent stent blockage from occurring. In this time period it is probably better to avoid elective surgery or if surgery needs to be undertaken, advice is sought from the treating cardiologist.

C. Warfarin

Drugs like Warfarin (Coumadin) which effect clotting pathways are usually stopped 5 – 7 days before surgery as this is the sort of time required for clotting to normalize. This can be checked with a simple blood test. Warfarin is often given to prevent stroke in individuals with cardiac arrhythmias such as atrial fibrillation, as a treatment for venous thrombosis and in patients with certain types of artificial cardiac valves. Sometimes in these circumstances Warfarin or similar agents need to be replaced with agents that have a short duration of action (Clexane/Heparin 24 hours) to provide anticoagulation cover until the day before surgery. If the matter is urgent Warfarin can be reversed quickly with VitaminK or infusion of fresh frozen plasma.

 

D. Oral Heparin-like Agents

Newer agents such as Rivaroxaban and Epixaban are becoming more frequently used instead of Warfarin because of their relatively short duration of effect and the fact that they don’t need to be constantly monitored with regular blood tests. These agents can generally be safely ceased the day before surgery.

E. Glucosamine/Chondroitin

It has been suggested in some studies that Glucosamine and Chondroitin and large doses of Omega-3 oils (fish oil/krill oil) can adversely affect clotting and should be ceased 14 days before surgery.

I’m generally happy for all these agents to be recommenced a couple of days after surgery, provided that ongoing blood loss has ceased and the patient’s condition is medically stable.

 

Other Medications Affecting Clotting

The oral contraceptive pill (OCP) and hormone replacement therapy (HRT) have been shown to increase clotting and therefore the risk of developing deep vein thrombosis. These agents should be ceased 1 week prior to any surgery where there is a significant risk of deep vein thrombosis – total knee and hip replacement procedures or major pelvic surgery.

 

Immunosuppressive Medications

These medications include Methotrexate, Humira, Arava etc and even Prednisolone or Cortisone by mouth and are often prescribed in individuals with auto-immune disorders such as rheumatoid, psoriatic and other inflammatory arthritis conditions. In a surgical setting, these drugs can make the body more susceptible to developing infection and impair the ability to fight infection. These drugs also retard normal skin and soft tissue healing. As such they pose a hazard, particularly in patients undergoing major surgery such as joint replacement procedures. These drugs should be ceased at least one half-life before surgery (usually 1-2 weeks) and should not be recommenced until wound healing has taken place (usually after post operative review at 2 weeks).

 

 

Drugs Affecting General Health

Cigarette smoking has been shown to retard bone healing. Smoking also increases anaesthetic risk and risk of developing post operative chest complications such as atelectasis and infection. Ceasing smoking as long as possible before any upcoming surgery will diminish these risks and in situations where bone healing is important (fracture treatment and joint replacement surgery), it is essential that smoking is avoided post operatively. This is common sense anyway in terms of improving general health.

 

Excessive long term alcohol consumption leads to impaired wound and soft tissue healing. Cessation and vitamin supplementation can reverse these effects in some individuals.

 

On the Day of Surgery

With surgical procedures scheduled on a morning operating list, patients are requested to fast from midnight. It is generally recommended that usual morning medications are not taken in this circumstance. The anaesthetist may allow some medications to be taken with a sip of water after pre operative anaesthetic consultation. For patients scheduled for surgery in the afternoon, it is generally recommended that usual morning medications are taken at about 0730 with a light breakfast before fasting commences.

For patients with diabetes, every effort is made to schedule these patients early on an operating list to avoid excessive fasting times. For morning list patients, do not take diabetic medications in the morning (oral tablets or insulin). A fingerprick blood glucose measurement is usually undertaken soon after admission to hospital and if low from fasting, glucose via a drip is often started after anaesthetic consult. For afternoon list patients it is recommended that half the normal dose of insulin or medication is taken with an early light breakfast and the same blood glucose measurement process is followed on admission to hospital and adjustments made accordingly.