For Matthew Solan & James Davis at St John & St Elizabeth Hospital and OneWelbeck

For Martin Klinke at London Bridge, Cromwell Hospital, Chiswick Outpatients, New Victoria Hospital & One Welbeck

Martin Klinke Case of the Month -Dec 2023

My patient who I shall call Mrs L is a very active lady who presented to my clinic in May 2019 aged 57 years, as she had injured her ankle 16 months earlier.

She initially went over on her ankle and because of persistent pain she saw a physiotherapist, had some shockwave treatment and as symptoms had not improved, she saw a local foot and ankle specialist.
Due to her injury her foot was tilting a little inwards and therefore she wore orthotics.

Clinically she was also unstable on the outside of her ankle, had a tight calf muscle and presented with a bunion. Her pain was mainly on the inside and the back of her ankle.

An MRI scan showed a small bony avulsion on the inside of her ankle and some inflammation along a tendon (tibialis posterior tendon) but no rupture of the tendon. The joints all looked good.

We both agreed that she should see a good podiatrist and she saw Mr Ivanoff who provided her with supportive insoles. Overall Mrs L felt better and due to Covid, she did not come back to see me for a check-up.

In January 2022 she sustained an avulsion fracture at the tip of the fibula and was seen on the NHS, she was given a boot which she wore for six weeks.

As symptoms did not really improve and she had ongoing pain on both sides of the ankle she came to see me again in July 2022. Mrs L felt unstable, had difficulties walking up and down stairs and even at night had some discomfort.

The new x rays showed an ununited fracture of the tip of the lateral malleolus and confirmed the bony avulsion of the medial malleolus. At this stage we agreed to continue with conservative treatment, including a soft ankle brace and an ultrasound guided injection around the inflammation of her painful lateral ankle. Her symptoms did not improve sufficiently and therefore she came to see me again in November 2022.

At the beginning of February 2023, Mrs L complained of persistent pain, and she felt that her symptoms were getting worse. She used to walk her two dogs daily but she was more and more limited in her activities. She complained of increasing pain on the outside and inside of the ankle joint.

Since having seen Mrs L the last time, her symptoms have not really changed.
Overall, she has the impression that she is potentially getting worse and feeling more and more limited in her activities. She was recently in New York and could not really walk as much as she wanted to, despite having all the appropriate footwear and support. She feels that she has lost her ‘spring’ and is limited in her walking. She also has pain on the lateral side.

Due to her increasing difficulties with daily activities, we discussed the situation again and decided to consider a surgical approach.

The fact that her malalignment of her hindfoot had caused to develop a bunion and an increasing tightness in her calf muscle, we agreed not only to take care of her ankle problems but also of the other problems.

On the 27th of February Mrs L had the operation to release her tight calf muscle, had a resection of the avulsed fragments of bone and the reattachment and tightening of the ligaments on the inside and outside of her ankle. Finally, we also straightened her bunion and corrected the lowered medial arch.

Postoperatively she was in a half cast to protect the ligament repair, but after a few weeks she was allowed to start partial weightbearing in a boot. After four weeks she started fully weightbearing and was in a post op shoe for another two weeks.

She had an X ray after six weeks which showed a good alignment of the ankle and foot, as well as a fully healed correction of her bunion. At this stage Mrs L was allowed to increase her activities, start walking around in supportive comfortable footwear, but when walking for longer distances and travelling, she had to continue to wear a brace.

At the last clinical review three months post operatively, Mrs L presented with very good stability of her ankle and was not tender to palpation or when stressing the joint.

Due to the calf release she had regained full flexibility of her ankle and her big toe was in a nice and straight position, with good flexibility and an improved longitudinal arch.

We therefore agreed that she could resume all activities including walking on uneven surface and doing impact exercises.

We did not arrange a follow up appointment as she was delighted with the result of the treatment and the operation.

Finally, I did receive this letter from the patient.

"As it is now just over 7 months since my surgery, I thought you would be interested to know how things are progressing.

My ankle is amazing. The strength and stability so far is more than I had ever expected and I am very happy that I am now confident enough to move around both on the boat, and on terra firma without any hesitation at all. I cannot tell you how happy I am about this. I wanted to write and let you know what an amazing job you did. I thought that my mobility may never recover, but it has tenfold!"

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