Brostrom-Gould Procedure for Lateral Ankle Instability

Abstract

Acute ankle sprains are most frequently treated conservatively, although some surgeons may advocate acute repairs in certain situations. Surgery is indicated for chronic sprains with persistent ankle instability despite well-designed conservative management. Several anatomic and nonanatomic operative procedures are available. The Broström-Gould procedure is a widely-used operative intervention for the treatment of chronic lateral ankle sprains. It consists of an anatomic repair or reconstruction of the injured lateral ankle ligament complex (Broström procedure), followed by suturing of the inferior extensor retinaculum to the periosteum of the distal fibula (Gould modification).

This article describes the standard Broström-Gould procedure starting with the identification of the anatomic landmarks. The skin incision follows the anterior border of the distal fibula, and careful subcutaneous dissection is carried out to expose the extensor retinaculum and the torn ligaments. This is followed by bone preparation and ligament repair utilizing a box stitch technique while holding the ankle in an appropriate position. Finally, the Gould portion of the procedure is demonstrated.

Keywords

Lateral ankle instability; chronic ankle sprains; foot and ankle; ankle ligament repair; Gould modification.

Case Overview

Background

Ankle injuries are among the most common complaints presenting to primary care and emergency departments.^1–5 The majority of acute tears are managed conservatively, except in the case of severe injury.⁶ Chronic ankle sprains may result, involving persistent ankle instability and/or pain refractory to conservative management for an acute ligament injury. Surgery is indicated for chronic sprains after initial management fails.⁷ A variety of procedures are available to aid in surgical correction; the Broström procedure is a widely-used intervention to address lateral ankle instability in association with a chronic sprain. The Broström procedure consists of an anatomic repair or reconstruction of the injured lateral ankle ligament complex, and it is often accompanied by the Gould modification, which subsequently attaches the inferior extensor retinaculum to the periosteum of the distal fibula via suture.⁷ 

Focused History of the Patient

This patient presented with lateral ankle instability in association with a chronic sprain. Her acute injury involved an inversion of a plantar-flexed foot leading to injury of the lateral ankle ligament complex. Persistent pain and instability were noted, and the patient underwent peroneal tendoscopy, which identified a chronic injury to the ligament complex and the need for definitive surgical repair.

In assessment of ankle injuries, obtaining information such as the nature of the injury, whether the patient could bear weight following the injury, and whether a prior injury has occurred is critical to the history for treatment planning purposes.^6, 8

Physical Exam

Ankle injuries often present with swelling and ecchymosis, which may or may not persist in chronic cases. Pain is also an important symptom and is used in grade determination.⁶ Palpation of the entire fibula is warranted, as well as areas required for the criteria within the Ottawa ankle rules. Additional physical exam tests should include determination of current weight-bearing ability, as well as special tests including the squeeze test, the external rotation stress test, the anterior drawer test, and the talar tilt test. It should be noted that these special tests are often clinically helpful but have not been studied extensively.⁶

Imaging

Plain radiographs are sufficient in diagnosing concomitant fractures in acute ankle sprains.⁶ Patient selection for radiography in acute injuries should be made in association with the Ottawa ankle rules.⁹ Ankle sprains with persistent pain up to 8 weeks following initial presentation may benefit from MRI to detect soft tissue injury, suspected syndesmosis, or talar dome fractures.^6, 10 Peroneal tendoscopy may be performed in refractory cases as a supplementary diagnostic measure.

Natural History

Approximately 30% of patients with acute sprains develop some degree of chronic ankle instability.^7, 11 Notably, a cohort study of patients with chronic ankle injury found no correlation between the severity of the initial injury and the degree of residual instability.¹² The majority of patients who develop chronic ankle injury will continue to demonstrate features of instability unless a surgical correction is performed, and surgery should be offered to patients who are avoiding or modifying daily or sporting activities as a result of the injury. 

Options for Treatment

For patients with chronic ankle instability or pain limiting daily or sporting functions, surgery is advised. Most patients will achieve satisfactory recovery via the Broström or Broström-Gould procedure;^13,14 however, in high-demand individuals and athletes, the standard Broström procedure may be inadequate, and additional augmentation, such as the Evans procedure involving split transfer of the peroneus brevis, may be performed.⁷

Rationale for Treatment

The purpose of the Broström procedure is to correct the injury to the lateral ankle ligament complex. The subsequent Gould modification attaches the inferior extensor retinaculum to the periosteum of the distal fibula via suture. The combination of these procedures corrects locally-scarred tissues in and around the ligament complex and provides sufficient stabilization in most patients.⁷

Discussion

This patient underwent successful repair of a chronic lateral ankle injury via the Broström-Gould procedure. A 6-cm skin incision was made following the anterior border of the distal fibula, starting 4 cm proximal to the tip of the fibula and curving toward the sinus tarsi, followed by careful subcutaneous dissection down to the extensor retinaculum and torn ligaments. The anterior central branch of the superior peroneal nerve was identified and preserved, as well as the sural nerve posteriorly. Bone preparation and ligament repair attaching the anterior talofibular ligament to the calcaneofibular ligament was performed using a box stitch technique with #1 Ethibond sutures while manually stabilizing the ankle in an appropriately-dorsiflexed and everted position. The Gould modification was performed, anchoring the inferior extensor retinaculum to the periosteum of the distal fibula via suture. A two-layer closure was performed, and wound dressing and posterior splinting were applied for the recovery period.

The Broström-Gould procedure offers several advantages that have made it a preferred surgical intervention for chronic lateral ankle instability. It is relatively simple to perform, uses a small cosmetic incision, protects the sural nerve, does not require the sacrifice of the peroneal tendon, and provides an anatomic reconstruction maintaining full range of motion with limited potential for locking the subtalar joint in eversion.⁷ Outcomes are good to excellent, with 85–95% of patients achieving a successful outcome without nerve injury or major complications.^13,14 A systematic review of 11 studies involving 669 Broström-Gould procedures reported a revision rate of 1.2% at a weighted mean follow-up period of 8.4 years.¹⁵ While open repair remains a standard and commonly-recommended approach, recent research investigating arthroscopic repair has demonstrated similar efficacy with smaller incisions, shorter recovery, and lower pain scores, but increased cost and operating times.^16–18

In certain high-demand individuals, the Broström-Gould procedure alone may provide an inadequate repair, and augmentation with an Evans procedure should be considered.⁷ First described in 1953, the Evans procedure involves division of the peroneus brevis tendon, passing of one muscle belly through a tunnel drilled into the fibula, and reattachment to the other muscle belly on the opposite side.¹⁹ Two modifications to this approach have been made since its initial description. The first is a routing of the entire peroneus brevis through the fibular tunnel posteriorly-superiorly, and then reattaching it to the periosteum or adjacent to its insertion at the base of the fifth metatarsal. This approach allows the reconstruction to act as a tenodesis rather than a dynamic stabilizer. The second modification is known as the “split Evans procedure,” in which a portion of the tendon is divided, passed through the fibular tunnel, and sutured to the fibular periosteum.²⁰ This approach reduces the potential concern for “locking” the subtalar joint in eversion, as with a standard Evans approach. Each of these augmentations may be considered in highly-active patients undergoing surgical repair for chronic lateral ankle instability. A retrospective case series of 19 patients undergoing a Broström-Evans modified repair identified minimal loss of peroneal strength, decreased inversion range of motion, and no recurrent instability or progressive symptomatic subtalar arthritis requiring reoperation at long-term follow-up.²¹ The decreased range of motion identified in these patients suggests that certain performance activities, such as dance, gymnastics, and ice skating may be contraindications to this augmented approach.⁷

Postoperative management for stabilizing procedures for lateral ankle instability involves placement in a non-weight bearing splint in slight plantar flexion and eversion for 2 weeks, followed by a weight-bearing cast in the neutral position for 2–3 weeks.⁷ Exercises and formal physical therapy are generally recommended at this point in recovery using a basic ankle brace. Inversion is generally avoided for up to 12 weeks, and cutting activities are avoided for 14–16 weeks. Sport-specific conditioning and a gradual return to sport usually occur at approximately 4 months postoperatively. 

Proprioceptive training may be an acceptable therapeutic modality for patients with chronic ankle instability before surgery. There is evidence to suggest that strength and balance exercises contribute to improved ankle strength, range of motion, and perceived ankle stability in comparison to usual care.^22–24 A systematic review of seven trials involving 3726 participants identified a statistically significant decrease in ankle sprain incidence in patients who had undergone proprioceptive training (RR=0.65, 95% CI 0.55–0.77), including patients with a history of ankle sprain (RR=0.64, 95% CI 0.51–0.81).²⁵ One study assessing a 6-week proprioceptive training program in 70 athletes with chronic ankle instability reported no significant difference in pain scores between intervention and control groups; however, further study is warranted as most studies have not identified pain as a primary outcome.²⁶ As such, proprioceptive training may have preventive or therapeutic benefit in patients with or at risk for a lateral ankle injury.⁶

Equipment

No special equipment used. 

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Additional Information

This article is the companion to the following JOMI articles by Dr. Eric Bluman, MD, PhD:

• Deltoid Ligament Repair
  
• Peroneal Tendon Debridement
  
• Five-Month Patient Follow-Up following Ankle Ligament Reconstruction