Rehabilitation of the ankle joint: recovery after injuries, arthrodesis, endoprosthetics

According to statistics, 54% of fractures and fracture-dislocations of the ankle joint occur at a young age, when it is important for a person to maintain working capacity. These injuries are classified as severe injuries to the musculoskeletal system. Even with high-quality treatment, they lead to disability in 3-12% of cases. Therefore, restoring the functions of the ankle joint requires a careful approach, individual for each patient.

The situation is similar with injuries to the ligamentous apparatus. The ankle is often injured in athletes and young, active people. In 30-50% of them, late diagnosis or poor-quality treatment leads to chronic instability of the ankle joint. It interferes with leading an active lifestyle, and over time even leads to disability.

Early diagnosis and quality treatment help reduce the risk of disability. Moreover, ligament injuries, sprains and fractures are much easier to treat initially, immediately after the injury. At the same time, the chances of restoring ankle function are much higher. And the treatment and rehabilitation itself is less invasive and takes less time.

Therefore, after an injury, it is better to immediately contact a good clinic, where they use the most effective diagnostic and treatment algorithms.

How to restore ankle function after injury

How doctors will treat depends on the severity of the injury and the nature of the damage to the joint. After all, ligament tears are much easier to treat than, for example, displaced fractures or fracture-dislocations. Specialists decide on treatment tactics only after examining the patient, having a complete understanding of his condition and the severity of the injury.

Several methods are used to restore the functions of the ankle joint:

1. Conservative treatment. Effective for minor injuries that are not accompanied by fractures, dislocations and complete rupture of ligaments. The functions of the ankle are restored with the help of rest, fixation with an elastic bandage, painkillers and anti-inflammatory drugs, physiotherapy and exercise therapy.
2. Plaster immobilization. Used in the treatment of fractures in which there is no displacement of the bone fragment and instability of the ankle. Plaster is also applied for fresh ruptures and tears of the ligaments (no later than two to three months after the injury). Plaster immobilization is also used after osteosynthesis and skeletal traction as a final treatment method.
3. Closed reduction with further plaster immobilization. Used for closed displaced fractures. It is not recommended for use in cases of concomitant ankle subluxations due to the high risk of unsatisfactory treatment outcome.
4. Open reduction with fixation with immersion structures. All open and some closed fractures are treated in this way. In some cases, after surgery, the joint is additionally fixed with plaster.
5. Skeletal traction and transosseous compression osteosynthesis. Used to treat complex and chronic fractures in the ankle joint. It is carried out using special external fixation devices.
6. Surgery. It is performed for chronic ligament injuries, post-traumatic osteoporosis, severe fractures and fracture-dislocations. Allows you to restore ankle function even when it is impossible to do this in other ways.

Ankle immobilization

For complete ruptures and significant tears of the ligaments, plaster immobilization or external fixation devices are used. However, they are effective only in the early stages, before a person has developed instability of the ankle joint. For old injuries that are more than 2-3 months old, these methods do not give the expected result.

If a person’s ligament rupture is not detected in time or he does not receive quality treatment, he develops ankle instability. In this case, no immobilization will help restore the function of the joint. And in order to return to work, it is necessary to undergo surgery.

General rules for walking on crutches

Different types of crutches are used for different situations. Usually, axillary crutches are used for the initial stage of rehabilitation after leg amputation, other operations, and plaster application. After completing the first stage of rehabilitation, when the patient is allowed to put minimal load on the injured limb, he can switch to elbow crutches, which are also called Canadian crutches.

It is important to choose the right shoes for walking on crutches. It is worth using familiar shoes that the person has worn before, so that the discomfort from using crutches is not added to the discomfort from new shoes. However, it is obvious that we are not talking about shoes with heels or high platforms. You should give preference to the most comfortable shoes for the season, which can be easily put on and taken off your feet, without complicated lacing or decorative elements.

When walking on crutches, you need to pay attention to the road . The ideal option is asphalt or a flat, compacted soil surface. Soft ground, grass, sand will not provide sufficiently solid support for crutches, and the patient may lose balance, and even a small stone or hole can cause a fall. You should move very carefully on wet or slippery surfaces.

During movement, it is necessary to pause and periodically rest , since the body is not accustomed to such loads, the muscles, especially the upper body, perform functions unusual for them, they are overstrained.

To use both axillary and elbow crutches, a person must have well-developed muscles of the arms, shoulder girdle, and torso. Doctors often advise frail and elderly people to use walkers instead of crutches.

Non-surgical treatment of fractures

Conservative treatment is possible only when there is no displacement of bone fragments and the ankle joint remains stable. In this case, the patient is given a plaster cast for 1-2 months or asked to wear a boot for rehabilitation walking.

Despite the availability and low-traumatic nature of plaster immobilization, it has a number of disadvantages:

• limits the mobility of the lower limb and complicates rehabilitation;
• disrupts peripheral circulation;
• causes irreversible changes in the neuromuscular system of the leg and foot.

In order to partially neutralize the harm of long-term immobilization, from the second or third day after applying the cast, a person begins to engage in therapeutic exercises. Exercise therapy helps relieve swelling, improve blood circulation in the ankle area, and strengthen the muscles of the foot, lower leg and thigh. And this speeds up recovery and prevents the development of post-traumatic osteoporosis.

After the cast is removed, rehabilitation continues for several more months. During this period, the patient is prescribed massage, physiotherapy, physical therapy, etc. The main goal of these procedures is to strengthen muscles and ligaments, improve metabolic processes in tissues, normalize blood circulation and restore the functions of the injured joint.

How to walk correctly on elbow crutches

Let us dwell on the rules for selecting arm crutches. The main task is to adjust the position of the cuffs and handles.

To check the position of the cuff, the patient stands up straight, places the crutch to the side 15 cm from the foot, and points his arm, bent at the elbow at an angle of 15-20 degrees, into the cuff. If the patient is about 1.7 m tall, the cuff should be at a distance of 5-7 cm from the elbow bend; if the patient is over 1.8 m tall, the distance should be about 10 cm; below 1.5 m – 4.5-5 cm. can also be performed while the patient is sitting. In this case, he puts the cuff on the arm and points the tip of the crutch straight up with the elbow bent 90 degrees. The width of the cuff is also important. It should not press or pinch your hand, and should not be overly wide.

The level of the palm handles is easy to check - with the patient standing straight with his arms down, the line of the wrist should correspond to the upper level of the handle. If the bend of the wrist is higher, then the crutches are shorter than necessary; if lower, the crutches are longer.

Walking on elbow crutches in general does not differ from walking on axillary crutches, with the difference that the fulcrum is in the elbow area. The crutches are alternately moved forward and slightly to the sides of the feet, while placing emphasis on the healthy leg, the sore leg is moved, then the healthy leg is taken a step.

Closed reduction with further plaster immobilization

This is a common treatment method used primarily for ankle fractures. Its essence lies in the manual reposition of bone fragments and subsequent fixation of the ankle with a plaster cast. This method is accessible and low-traumatic, but has its drawbacks.

Long-term plaster immobilization disrupts trophism and impairs blood circulation in the tissues of the limb, causing irreversible changes in the nerves and muscles of the lower leg, foot, and ankle joint. It does not provide sufficiently stable fixation and does not guarantee complete immobility of the fragments. All this can lead to improper bone fusion and the formation of a false joint.

In case of concomitant dislocations and subluxations of the ankle, it is recommended not to use closed reduction. The reason is the high risk of unsatisfactory treatment results.

The most common of them:

• postoperative contractures;
• false joints;
• severe deforming arthrosis.

Therefore, many specialists prefer a different approach to the treatment of displaced fractures. For patients of working age, they recommend open reduction with fixation of bone fragments with metal structures. And for patients in the older age group, reposition under image intensifier control and fixation with Kirschner wires.

How to walk correctly on axillary crutches

The main condition for comfortable movement on crutches is their correct selection. There are two main criteria: the overall height of the crutch and the location of the palm rest.

To calculate the total height of the crutch, you need to subtract 40 cm from the person’s height (in cm). When measuring height, it is necessary that the person is wearing the shoes in which he will most often walk on crutches, or a sole height that is close to it. The crutch for measurement is not placed strictly vertically, but 15-20 cm to the side of the foot, and its top crossbar should be 4-5 cm below the armpit level.

To determine the location of the palm support, the patient leans on crutches, bending his arms at an angle of about 30 degrees. In this case, the crossbar should be at palm level. If a person stands with his arms straight down, the support should be slightly above the line of the wrists.

Correct selection of height is very important - if the crutches are too high, the pressure on the armpits increases. This, in addition to discomfort, abrasions, and rashes, can cause serious consequences. One of them is radial nerve palsy. This condition is characterized by weakness of the wrist and hand and loss of sensation in the back of the hand. Paralysis goes away after the pressure normalizes, but it is better to prevent its occurrence.

In order to move correctly on crutches, you need to remember a simple algorithm:

1. Before moving around to get out of a chair or bed, crutches should be on the side of the injured leg. The patient grabs them from the inside, transfers one of the crutches to the other hand and, straightening the injured limb, carefully stands up.
2. The patient places the crutches strictly vertically on the side of each leg. The width between the shoulder pads should be sufficient for the torso to fit between them. The palms are on the support.
3. Leaning on both crutches, the patient transfers his body weight to his healthy leg.
4. The crutches are moved forward one step at a time, then the person transfers the body weight to the crutches, moves the sore leg forward, at the same level as the crutches, holds it in weight or carefully leans on the foot or toe, and moves the healthy leg one step ahead of the sore one. The correct position of crutches when walking is not in close proximity to the foot, but at a distance of about 15-20 cm to the side.
5. The patient rests the foot of his healthy leg on the floor or road and repeats the previous actions.

For those who are just learning to walk on crutches, it may be easier to start with shuttle walking. With this method, the crutches are first moved forward, then the patient transfers his body weight to them, leaning on his hands, and first pulls up the diseased and then the healthy leg.

The main emphasis on crutches is made not by the armpits, but by the palms, and it is necessary to use the muscles of the arms. But you shouldn’t squeeze the bar too tightly with your palms, as this can lead to numbness in your fingers and cramps.

When walking, you need to keep your head straight and your body as straight as possible, without bending your back. When turning, you should lean on your healthy leg. If you need to carry some things, it is better to use a backpack or a belt bag; a bag on your shoulder will interfere with movement. When climbing a hill, you need to make sure that the crutches do not remain behind the body.

Open reduction with internal fixation

The method is used to treat complex fractures when manual reposition of fragments and holding them in the desired position with the help of plaster is impossible. To compare bone fragments and securely fix them, submersible elements and structures are used:

• tie bolts;
• screws;
• bolts with clamp terminals;
• Kirschner wires;
• bolts with flexible rod;
• lavsan ribbons and so on.

Open reduction ensures immediate accurate comparison of fragments and their reliable fixation. After surgery, early weight-bearing ability of the limb is often preserved, which allows it to be loaded soon after surgery. Nevertheless, many experts are confident that none of the methods of open reduction can ensure complete immobility of bone fragments. Therefore, after surgery, patients require additional plaster immobilization.

Operative comparison and fixation of fragments has other disadvantages:

1. Injury to soft tissue at the surgical site.
2. Risk of developing infectious complications.
3. The likelihood of secondary displacement of fragments due to failure of fixators.
4. High incidence of pseudarthrosis.

In some cases, closed fractures are best treated by skeletal traction or transosseous osteosynthesis. These methods exclude the intervention of a traumatologist in the natural healing process. Regeneration is accelerated because the doctor does not remove the hematoma and does not damage the muscles, blood vessels, or periosteum. And the opposition of fragments and stretching of soft tissues additionally stimulates regenerative processes.

Transosseous osteosynthesis

Today, osteosynthesis is carried out using hinge-distraction devices and skeletal traction devices. The technique allows you to reliably fix bone fragments, which creates ideal conditions for their fusion.

The main advantage of transosseous osteosynthesis is that it does not require open surgery. The disadvantage is that it does not always allow bone fragments to be compared. Therefore, transosseous osteosynthesis can be combined with surgery. First, the fragments are connected surgically, and why the bones are additionally fixed with an external fixation device.

Platform rotation

• Rotate the balancing platform clockwise until its edge is in constant contact with the floor , then counterclockwise. Repeat 30 times in each direction.
• Rotate the balancing platform clockwise until its edge touches the floor , then counterclockwise. Repeat 30 times in each direction.

Reconstructive surgeries

Reconstructive surgeries are used to treat chronic ligament tears that are accompanied by ankle instability. The integrity of the ligaments is restored surgically, after which the joint is fixed with an Ilizarov apparatus. If the injury is less than 5 months old, surgery is often performed by arthroscopy. But old ruptures require open reconstruction.

The integrity of the ligaments can be restored:

• local tissues;
• allotissues;
• synthetic endoprostheses.

Plastic surgery with local tissue is associated with additional trauma to the donor site, so it is rarely performed. To restore ligaments, synthetic tissue or allotendon is often used.

Endoprosthetics and arthrodesis

Surgeries on the ankle joint are performed mainly for severe post-traumatic osteoporosis, which is accompanied by severe pain and limited mobility of the ankle.

Young patients often undergo endoprosthesis replacement - replacement of a joint with an artificial endoprosthesis. This operation allows you to completely restore the function of the ankle. When endoprosthesis replacement is not possible (old age, severe concomitant diseases), the patient undergoes arthrodesis - immobilization of the joint. This operation is resorted to as a last resort.

Let's summarize:

1. Torn ligaments and ankle fractures often occur at a young age. They are difficult to treat and often lead to disability.
2. Fresh injuries are much easier to treat. The sooner a person receives medical help, the higher the chances that joint function will be restored.
3. To treat injuries, different methods are used, ranging from conservative treatment to surgical treatment.
4. The choice of treatment method depends on many factors. The severity and duration of the injury, ankle instability, the degree of post-traumatic osteoporosis, etc. play a role.
5. Surgery is a radical method of treatment. As a rule, surgery is performed when it is impossible to restore the function of the joint in other ways.