My experience with Brostrom Surgery – Ankle Ligament Repair

Back when I was in boy scouts, our scout troop leader had a limp. He lamented to us often about the importance of good boots. But I was young then and I figured I had nothing to worry about. In college I took up jogging, and every now and then would trip and twist my ankle. No big deal. But over the years the trips and sprains added up. The big ones stick in my mind; sprains while hiking down from overnight camping trips, trips while trail running, trips while out for a morning run.

My mother cautioned me to look after my ankle. She said I would get arthritis. But I figured arthritis was for old people, so I didn’t pay much attention.

The years passed by, the sprains kept coming. Then there were a few good sprains that put me out of running for months. Compression socks from different countries started to pile up in my drawers. I started wearing an Active Ankle brace occasionally, then all the time. Along the way, I saw a few doctors who diagnosed ‘chronic ankle instability’ and recommended ankle strengthening exercises. I did my best to improve my balance with my eyes shut while washing my teeth, but there didn’t seem to be much more that I could do; except be careful.

I wish I’d known….

Whenever I sprained my ankle, I would wrap it up with one of those ACE bandages that you get at the drugstore. They didn’t really add much support.

What would have worked better for hiking and running would have been an ASO Lace-up Ankle Brace

Eventually, I stopped running; it wasn’t worth the risk. I stopped hiking; it also wasn’t worth the risk. But by then I would sprain my ankle crossing the street or even doing laundry. The ankle started to ache… not badly, but noticeable. So, with insurance in hand, I went to get some long overdue physical therapy.

By this point the physio laughed at me, and said there was nothing she could really do. Time to talk to a surgeon.

Ankle Ligaments.

Inversion sprains are the most common types of sprain where the foot bends outwards. There are three ligaments that are designed to keep things in place, but repeated injuries will weaken and eventually tear these completely. The doctor knew right away from pulling my ankle out at a funny angle, and the MRI confirmed: Two of my ligaments, the ATFL and CFL were completely torn. Only the strength of my muscles kept me upright.

Fortunately, modern medicine has a few tricks up it’s sleeve and the Brostrom Repair is one of them. The ligaments can be sewn back together, and they’ll reattach, stronger than new apparently.

The MRI also showed other damage. With each sprain, the corners of the bone starts to grind into the cartilage. Eventually that cartilage started to rub away and the result was friction where the bone starts to grind on bone. The associated inflammation and pain is known as arthritis and it’s bad news. The arthritis damage is less easy to fix, but a technique called ‘micro-fracturing’ of the bone makes it possible for the body red blood cells to escape and regrow some insulating material where the cartilage had formerly been.

With trepidation, I signed myself up.

Brostrom Repair – The Surgery

I had my surgery done with Daniel Thuillier at UCSF. This surgery has a high degree of success, and even though my ankle started to feel better in the months before surgery, both my PT and the doctor felt this was the right decision long-term.

The morning of the surgery, I was nervous. I took a long walk down by the canal in the morning drizzle before I went in, and then I resigned myself to the professionals.

Leg shaved, colored pens to mark which ankle they were going to operate on, IV drip hooked up, sedatives infused, ultrasound to find the leg nerves and a nerve block applied, and then I was wheeled into the OR, strapped in and a couple short breaths later…

…. I woke up. It didn’t feel bad. In fact I felt fine like I’d just taken a morning nap. My foot was all nicely packaged up. The nerve block was clearly doing it’s thing as there was no pain at all. They kicked me out of the hospital soon after, and I rode home to enjoy two weeks under house arrest.

Elevation is key to reducing swelling, so I lay back on my bed, with my foot propped up on a multitude of pillows. The nerve block lasts about 12-18 hours

After the nerve block wears off, the pain kicks in. They sent me home with prescriptions for lots of ibuprofen and opioids (oxycodone). Apparently it’s important to ‘get ahead’ of the pain. It’s much harder to use the drugs to overcome the pain once it arrives. So I signed myself up for the basic dose before I went to sleep and braced myself for the pain to come.

Surprisingly, severe pain didn’t come. The drugs did their job and I felt fine and only slightly loopy. By morning I could move my toes, and the pain level was probably at no more than a 2. If there’s one thing that I could pass on to others going through this, it’s that it wasn’t that bad… at all.

The next couple days, it’s best to remain in bed, and believe me, I had no desire to be up and about. I drank lots, and repurposed a laundry detergent container into a bedpan. The drugs stop up the rest of your system, so you don’t have to worry about #2 for a couple days. Then you have to start worrying about #2.

After a couple days in bed, I was ready to get up and move around.

Life on crutches.

Ok. So there’s a shopping list of things you need to prepare for.

1. You’ll want to shower. You can buy a waterproof covering that will go over your cast and keep everything dry. Buy it.

2. Don’t use the underarm crutches. They’re awkward, uncomfortable and can cause nerve damage even when you have them adjusted properly. Instead go buy some forearm crutches – also known as Canadian crutches, or Euro crutches, or quite frankly Rest-of-the-World crutches. It seems only America is stuck in the mid-1800’s with it’s preference for underarm crutches. Believe me, forearm crutches are the single best piece of advice I can give. You can buy a pair for $40.

After two weeks of hobbling around the house and keeping my foot elevated, the doctor took my stitches out, put me in a boot and allowed me to go out.

Note on the boot. UCSF charged my insurance over $1000 for the boot. If I’d bought the boot without insurance it might have only been $700. But go look on Amazon, you’ll find the same boot for $65!!! – A damning indictment on the state of over-charging in American healthcare.

Be careful of those knee scooters. One friend clipped a cubicle while zipping around the office and put herself back in hospital.

The first couple weeks on crutches is hard. Hard on your hands, hard on your self-confidence. This is offset by the ample kindness and generosity exhibited by almost everyone. Buses would wait for me, people would hold open doors, carry my food, strike up random conversations. I would go so far as to describe this period of convalescence as both character-building and life affirming.

Driving with your left foot

Since I’d had surgery on my right foot, I was told I couldn’t drive for six weeks.

Right. You can’t walk, and now you can’t drive?

I refitted the car with a left-foot accelerator made out of soldered copper pipe. Now you might think this a crazy idea, and everyone warned me against it, but in reality it wasn’t much different than driving on the left side of the road. There’s a mental shift, but it happens fairly quickly. You do need to be very cautious as you get started, and you do want to keep that right foot out of the way. I swung mine over to the passenger seat, so that muscle memory would know it had no role in hitting the brake should a surprise arise. It was left foot or nothing, and the left foot rose to the challenge.

Rehab

The weeks passed quickly. My arms grew strong. My disabled parking placard came. I learned how to carry a cup of coffee while walking slowly on crutches. The scar healed; it healed well. The boot became comfortable, and then it was time to move on.

Six Weeks

Up until six weeks, I’d successfully managed to stay off my foot (with only a couple minor mishaps). My pain level had never been above 3. I figured I was through the worst, and would soon be able to throw away the crutches and start dancing. Wrong. The fun was only getting started.

Six weeks of non-weight bearing had left my leg a shrunken noodle. As I started to move my foot, all sorts of stuff started to feel wrong. My leg muscles started cramping up at night. The foot was bruised, tingly and uncomfortable. Pain would shoot out as I started to put partial weight on the foot while walking in crutches

But the boot came off, and it was soon time for physical therapy!

Nine Weeks

Physical therapy started with range of motion and simple exercises to bring the muscles back to life. I was soon on an exercise bike every other day, and 30mins on the bike seemed to leave me a little more mobile than before. Walking with the crutches became more natural. One day, I found I was able to stand. The next I was able to stand up. Then I could walk across the kitchen unaided. Soon I found myself able to walk up stairs, then down stairs. I’d take the crutches for longer walks. I was able to get around.

Friends came to visit, and I took them to Yosemite. I managed to walk the Vernal Falls circuit partially weight bearing with the underarm crutches, up slippy rocks, and through snow. My physical therapist was not amused. But I think I will use forearm crutches for all hiking in the future. It’s fast and easy, and everyone seems delighted to see a cripple with determination.

Twelve Weeks

After three months, the crutches are in the basement, but my ankle is still sore and stiff. Every day is better though and I’m back on my bicycle, and back to swimming. I’m able to walk to the store, and every week the limp seems to be less. Doctor says this is completely to be expected at this stage.

Six Months

Recovery is definitely plateau-ing. My ankle is much more stable, and I am comfortably getting around on it, but it still aches and it doesn’t feel good to run on it. I can make it maybe a half mile, but after that it lets me know that it definitely isn’t happy. I saw the doc, and he recommended I go easy on it and see where we’re at after a year. That feels right. I’m still hopeful for a full recovery, although a little fearful that my running days are over.

Twelve Months

I’m back to running again. Not a lot, but I can comfortably trot out four or five miles now, which is all I’m after really. After a longer run, my ankle will ache for the next 24 hours, which I assume is from scar tissue and inflammation around the damaged cartilage. Nothing that a little ibuprofen and a bit of ice doesn’t take care of. I only run once a week or so as part of a a varied exercise routine, so perhaps I should push it more and see if it sorts itself out. The biggest improvement is that my ankle now feels much, much, more stable. I’m more confident on my feet, and that cloud of worry on uneven ground seems a lot less heavy.

Eighteen Months

Running a couple times a week now, without any noticeable problems from the surgery. My foot feels strong and stable. So, at this point, I’m really happy. It took a while to get to 100%, but it was well worth doing!

Two Years

So it felt great being able to put my running shoes on and go explore new places. I started regularly running again and loved it. And then, on a gorgeous morning in the Marin headlands, my foot landed funky on a rock.

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It was such a bad twist that I couldn’t even hobble out. I just lay there on the trail for hours until some friends and the park ranger hiked in with my old crutches. I was devastated.

Long story short… that put me out of action for most of this year. I started re-twisting my ankle again on stupid things, so I went back to the doctor fearing all had been undone.

All hadn’t been undone. The Brostrom repair is a strong one, but I am learning the hard way that ankle laxity and proprioception are issues that I need to continue working on with physical therapy and exercises. Just getting the surgery doesn’t fix it. I’m hoping surgery, plus vigilance, plus exercises and strengthening will.

I’m back to running short distances down the beach!

Good Links

• BWH – Guide to Brostrom Repair
• UW Guide to Brostrom Repair
• Article with yucky pictures
• NHS (Royal Berkshire) Guide to Brostrom Repair
• NHS (Guys & Thomas) Guide to Brostrom Repair
• Stone Clinic Guide to Brostrom Repair