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Modified Brostrom Procedure


Chronic ankle instability is a potential sequel to acute ankle sprains and refers to persistent giving way of the ankle. There are a number of causes of ankle instability including structural instability, functional instability and pseudo-instability.  Functional instability describes an instability that is secondary to a proprioceptive deficit  Functional instability is most effectively addressed with an appropriate  physiotherapy lead rehabilitation programme, to restore proprioception and coordination. Pseudo-instability is a feeling of instability in the ankle; In pseudo-instability the ankle usually doesn’t give way completely, individuals are often able to protect the ankle before it gives way and they might complain of a consistent feeling of catching or discomfort prior to the ankle giving. Pseudo-instability is usually caused by pain generators such as loose bodies or osteochondral lesions of the ankle.

Structural instability refers to an instability that is secondary to laxity of the ankle ligaments, usually the anterior talo-fibular (ATFL) and the calcaneo-fibular ligament(CFL). Structural instability is characterised by an increased  excursion of the talus relative to the ankle mortise. At initial presentation, many patients with structural instability will have a degree of functional instability  as well. The functional element of instability should be addressed with a course of functional rehabilitation with a physiotherapist before addressing the structural element. Even patients with  significant structural instability may compensate satisfactorily by improving the functional component of their instability.

Those patients with persistent structural instability, despite adequate physiotherapy, may benefit from surgery  to stabilise the ankle, which aims to address the structural component by repairing or re-constructing the ATFL and CFL.

One surgical technique that provides excellent results was first described by Brostrom in 1966, whereby the ATFL and CFL are repaired under tension. Gould in 1980 described a modification, incorporating an additional imbrication of the inferior extensor retinaculum (IER). The Bröstrom-Gould technique forms the mainstay of anatomic ankle reconstruction techniques, not only because of the high success rates, but also because of low rates of complication, such as ankle stiffness, subtalar arthritis and nerve injury. The procedure also restores the normal kinematics of the joint. Unlike the anatomical repair, non anatomical reconstructions(such as the Chrisman-Snook or Evans procedure) may not restore normal kinematics of the joint and usually involve larger dissections with a higher complication rate, most notably nerve injury and subtalar stiffness.

Readers will also find the following OrthOracle surgical techniques of interest:

Brostrom lateral ligament reconstruction using JuggerKnot soft tissue anchor(Zimmer-Biomet).

Lateral ankle ligament reconstruction

Ankle arthroscopy using the Smith and Nephew Guhl non-invasive ankle distractor

Peroneal sheath reconstruction (for peroneal tendon subluxation)

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- See: Ankle Sprains

- Discussion:
- indications:
- clinical symptoms are chief indications (radiographic findings may or may not correlate w/ the severity of the sprain and ankle dysfunction;
    - associated injuries:
- longitudinal tear of the peroneus brevis:
- contra-indications:
- fixed heel varus;
- obese patients;

- Radiographs:      

It is estimated that, in the UK, there are approximately 7000 ankle sprains per day. 85% of these sprains will involve the anterior talo-fibular (ATFL) and calcaneo-fibular (CFL) ligaments which are the principal lateral ligament restraints. Most will resolve with little input other than basic remedies such as rest, ice, compression and elevation. In those cases that do not recover quickly, it is either because they have been subjected to repeated sprains or there is a concomitant pathology such as an osteochondral lesions of the talus, peroneal tendon tears or peroneal retinaculum injury.

In those cases where non-operative treatment fails, surgical intervention may be necessary with the aim of restoring ankle stability by repair of the lateral ligament complex which can be done using the Zimmer Biomet JuggerKnot soft (suture) anchor. One surgical technique that has continued good results was first described by Brostrom in 1966, whereby the ATFL and CFL are imbricated, with an additional modification by Gould in 1980 which detailed additional imbrication of the inferior extensor retinaculum (IER). This technique forms the mainstay of anatomic ankle reconstruction techniques not only because of the high success rates but also because of low rates of complication such as ankle stiffness and subtalar arthritis.

The advantage of the Zimmer Biomet JuggerKnot soft tissue anchor system is that it offers excellent pull-out strength at the bone-anchor interface with a minimal footprint in the bone.

Author: Mark B Davies FRCS (Tr & Orth)

Institution: The Northern General Hospital, Sheffield. 

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- Surgical Technique:
- curvilinear incision is made over distal anterior border of lateral malleolus;
- if peroneal tendon exploration is necessary, then consider a posterolateral longitudinal incision;
- beware of peroneal tendons inferiorly, sural nerve (which lies over the peroneal tendons), lesser saphenous vein (which can be ligated), and branches of the superficial peroneal nerve (intermediate dorsal cutaneous nerve);
- after dissection procedes through subQ tissue, identify and preserve the inferior extensor retinaculum, which runs parallel to the CFL;
- this is mobilized for later attachment to the anterior edge of the fibula;
- identify the ATFL, which appears as a thickening in the anterior joint capsule;
- if it is torn, it is usually torn from the fibula;
- make anterior capsular incision along anterior margin of fibula down to its, distal tip, leaving a small cuff of tissue attached to the fibula (to facilitate later repair);
- identify the CFL at the inferior tip of the fibula;
- ankle is then placed in valgus and dorsiflexion, and the redundency of the ligament is assessed;
- sutures are passed thru the proximal edges of the ATFL and CFL;
- drill holes are made in the distal fibula;
- sutures are passed thru the drill holes, and are tied;
- the posterior edge of the extensor retinaculum is then opposed to the anterior edge of the fibula;
- this advancement of the retinaculum will help re-enforce the repair, limits the inversion, and addresses associated subtal instability;
- modified procedure using peroneus brevis:
- procedure results in significant loss of eversion and inversion;
- tendon harvest:
- procedure involves exposure of the peroneus brevis, while maintaining the integrity of the superior peroneal retinaculum;
- anterior third of the tendon is isolated distally and split from the distal position to the musculoskeletal junction;
- this tendon portion is transected at its proximal aspect;
- tendon anchorage:
- a drill hole is made through the distal fibula, and the split portion of the peroneus brevis is passed thru this hole;
- tendon is tensioned with the foot in mild plantar flexion and eversion;
- post op care:
- standard involves 6 weeks of casting, but there is some evidence that there are better functional results with 3 weeks of casting

- Outcomes:
- in the report by Messer TM, et al, the authors evaluated 22 patients with chronic lateral ankle instability who underwent surgical repair of their lateral ankle ligaments using suture anchors as part of the modified Brostrom procedure;
- at a mean follow-up of 34.5 months (minimum of 18 months), 20 patients (91%) reported a good or excellent functional outcome as assessed by the Karlsson and Peterson ankle function scoring scale;
- 14 of the 16 patients had no evidence of instability on exam or on stress radiographs;
- 1 patient had diminished sensation in the superficial peroneal nerve distribution;
- 5 of the 16 patients had generalized ligamentous laxity; none of these had an excellent result, and they had lower "Overall Satisfaction" scores (P = 0.013)

Sprained ankles. VI. Surgical treatment of "chronic" ligament ruptures.

The Modified Brostrom Procedure for Lateral Ankle Instability.

Ankle Instability Repair: The Brostrom-Gould Procedure
W.G. Hamilton   Master Techniques in Orthopaedic Surgery. The Foot and Ankle.  Raven Press, Ltd. New York, 1994.

Reconstruction of the lateral ligaments of the ankle using a regional periosteal flap.

Clinical Instability of the Modified Brostrom Evans Procedure to Restore Ankle Instability.

Treatment of Ruptures of the Lateral Ankle Ligaments: A Meta-Analysis.

Outcome of the modified Brostrom procedure for chronic lateral ankle instability using suture anchors.

Comprehensive reconstruction of the lateral ankle for chronic instability using a free gracilis graft.

Long-term results after modified Brostrom procedure without calcaneofibular ligament reconstruction