Brostrom-Gould Procedure for Lateral Ankle Instability

CHAPTER 1

So, what we're getting ready to do right now is a classic lateral ankle ligament repair, namely the Brostrom-Gould Procedure. I'm going to use a fairly standard incision that allows good exposure of the joint line and allows good identification and mobilization of the tissues that we're going to need to reef up and repair. So I’ve got my fibula depicted here with the hash marks we've already done a peroneal tendoscopy here, and that's what these sutures are. We're going to go ahead and fix the lateral ankle ligament complex here. So, essentially, I'm going to initially find where the lateral shoulder of the talus is and it's right about here, we're not going to need to go up any farther than that. I'm feeling the distal fibula here, and tip of the fibula is really down here so going right down along here is going to provide us with good access to the lateral ankle ligaments. One of the questions that is commonly brought up is that this could be at near right angles to incisions if you need to come down and do a tendon repair or do a fibular fracture in the future. And - I haven't come across any problems with tissue necrosis or poor healing in these cases and I think this is a safe combination to make, especially if they're separated temporally from each other. So we'll go ahead and start this portion of the case.

CHAPTER 2

So we’ll make this incision here, go through here, watch out and make sure that we're identifying and protecting branches of the superficial peroneal nerve. I'm going to do a little bit of dissection here, using a Jake right here just to mobilize some of these vessels. Try to preserve as many of these draining vessels as possible, but in this case it's we’re going to have to take these vessels. I haven't had any problems with significant swelling postoperatively secondary to decreased vascular outflow. That might be a little branch there, huh? This looks like a little superficial branch of the superficial peroneal nerve so we're going to leave that alone and I'm going to skeletonize it just a little bit to make it a little more mobile, so we can move it out of the way, but I think we're going to be able to retract it out of the way.

Go ahead and give me a Ragnell, please. I think we're pretty good, otherwise. It's looking good. Yeah, maybe it’s a little branch - could be. Give me a knife, please.

CHAPTER 3

Now I’m just going to go back to the knife and I'm going to open up the - there's a little bit of fatty tissue here. And I think this is it here, and I'm just going to - just gonna raise up - raise up some of that. You can see here, this is a layer that's developing. And that's going to be I think helpful for us. Down here we're going to be close, very very close, to the peroneal tendons. And we want to make sure that we're not damaging those. This is this is the retinacular fibers here, I'm going to switch hands here and just develop this underneath. You can see here's capsule underneath us, and this is some extensor retinaculum right here as well, and I'm going to develop this plane because it's going to be a a nice little pants-over-vest, I think, later on. So now I’ll go up right underneath this. And in this patient, it's a pretty stout layer, which is good. It's going to help us. You know, she's pretty much plantar-flexed and inverted, which is not where she's going to end up and I think we're going to be able to mobilize that very very well later on. So here's a little bit extra tissue that we're going to be able to incorporate that, and I'm just bluntly coming up on the distal fibula, which is right here.

And what I'm doing now is I'm actually feeling to say, okay, where am I going to make my incision here in this very much attenuated portion of the capsule. There no rents in it but you can see it's pretty beat up and scarred in. This is a lot of scar tissue here attached, and that's peroneals, right in here, you can see them and that's about as distal as we're going to have to go even if we have to go into the to the CFL. I'm feeling here for the joint line. Let me have a knife, please. And I'm going to go right in here. Right off the distal fibula, and I'm going to lift this tissue. This is the ATFL, and it's moving down into the CFL. More posterior, right? Yeah, more inferior and posterior. This is just scar tissue here that I'm going to release from the distal fibula and it’s going to allow me to eventually look into the joint. You want to readjust? Okay, so again this is now the extensor retinaculum here.

What we're going to use for our Gould modification, and I'm lifting up the tendon - rather, excuse me - the ATFL off of the fibula, and I'm also going to create... A little... Bare spot on the fibula for this tissue to heal down onto. You can see some of that fluid coming out from the joint. Can I have a freer, please? We're just releasing some of the scar tissue underneath so that she has - we got some excursion, and we can actually reef it up to a place where she's stable. Again, I'm clearing off tissue from the distal fibula to leave a nice footprint for this to heal back down to.

CHAPTER 4

I’m developing that plane between the talus now. You can see the talus in here. And we really need to free up all the tissue in there. Knife, please. And there's the fibular cartilage, right there. That really released it and that's good because now we can hike that up.

Let’s take a quick look at the CFL. Actually surprising the CFL looks fairly intact here. ATFL is clearly out.

CHAPTER 5

Alright so now we've got - we're able to do our repair, and we're going to ask for some #1 Ethibond sutures if we have it. And so this is our, again this is our capsule here. And then this is the extensor retinaculum right here that we're going to use to reef over. And probably attach it to this tissue at the end. So we're going to take our ligamentous tissue and do a repair right now. We’re going to put probably 3 sutures in there. Okay. So this is some pretty heavy gauge, non-absorbable suture we're going to use for this. And what I'm going to do is create a stitch that we're going to be able to use. Take this out of the way, please. This is our cuff from before... I think we're going to be able to put three good sutures in this location. I'm going to put a stitch in through here. Do we have anything on a smaller needle? You have a 1? That is a #1. This is the smallest needle we got? Yep. Okay. So I’m going to put what we call a little box stitch here. I'm going to come up through here in this tissue, and we're really going to take a pretty healthy bite to reef it up. And create a little box stitch, which I'm going to hopefully illustrate for you guys, right here. You usually start out with something akin to a horizontal mattress suture. Then you’re going to come back underneath the tissue cuff. And that suture is going to be a reinforcement for another stitch. You're going to take right here. It’s more of a cross stitch, but we call it a box stitch. And then this is going to come back up through that tissue sleeve that we created before. One more, you’re right. And again we’re just going to do a repeat of what we just did. Box stitch coming through the proximal sleeve. So again we got this cross stitch right here. I don't know if you guys can see it in close up. It’s a little cross stitch - box stitch. And again we’re going to finish up with a little going proximal, grabbing a nice tissue bite. So now - I think we're going to be alright. We’re going to have nice coaptation of that tissue, I think. Yeah it's perfect. Do you have a snap? Or snaps? Okay so we tie from inferior first. So what I'm going to do is - we're gonna tie it off here, and put a little, yeah, a little clamp on it just to hold it in place. We're not going to snap it down on the suture we're just going to hold it in place on the tissues just like this. You'll see what I'm talking about here so - no, not yet, not yet. Hold that up please. Yep. That's going to lock that suture down for me. Cut that off. And then the other one, we're going to do the same thing. Greg, with the other hand please. Hold this here. Yeah, and move this up here. A little bit more. A little bit deeper, okay. You can see that’s going to reef that up very nicely.

Now, we’re going to keep the good position of the foot dorsiflexion and eversion, and now I'm going to take the Vicryl suture and oversew this repair that I just did - figure-of-eight sutures. Have any preference for interrupted versus running? Yeah, I think that this is a strength - definitely strength sutures. I think they all need to be interrupted.

That completes that the Brostrom portion, and now what we need to do is - you can see that that that holds pretty nicely, but we're going to do is take this retinaculum that we developed earlier and actually sew it. Look at this. Take that down, we’ll reef those two together pretty tightly. And I think this is going to be a nice augmentation to our to Brostrom. So here we go again. Here's the retinaculum. And I do this with absorbable. This is pretty superficial underneath the skin. Certainly in thin people, ladies, you know it can be very prominent - the knots can be prominent if you're using non-absorbables, especially large gauge sutures. So you can see that - look at that nice, coming together - reefed. Again, I'm taking pretty generous bites here because I'm going to use this to strengthen and reinforce the repair. Bringing the tissues together is going to tighten this up. When would you consider doing bone tunnels? Good question - I do bone tunnels when I'm doing a combined open peroneal procedure and Brostrom. And I do all the bone tunnels straight through the fibula and tie it right on the backside I also repair - you're reefing your ATFL and your lateral ligament complex with the same sutures that you're using to close your superior peroneal retinaculum. The other thing that people do is - suture anchors - I think it's fine. I sometimes do that. If I can't mobilize the tissue on the top or I'm worried that I'm not going to have a very stable repair, I'll do that. And again, this is looking pretty good. You're seeing the superior peroneal retinaculum. The tissues have been reefed closed. They're nice and stable.

I'm gonna give it a little test now on the lateral side to see if her - and she's nice and stable now. I don't see any sulcus sign. I don't see any big movement there. That's a very stable repair.

CHAPTER 6

Now, what we'll do is I'll keep this... Some irrigation, please. I'll keep this dorsiflexion and eversion so I don't stress the repair during the closure. I do a two layer closure - subcutaneous layer and skin. And then we're going to go dorsiflexion, everted splint to hold her in a good position while this heals.