Modified Broström procedure for lateral ligament repair1

Symptomatic, recurrent lateral ankle ligament sprains

Failure of ankle instability to resolve despite physiotherapy to restore peroneal strength and ankle proprioception

Fixed coronal hindfoot malalignment

Degenerative and inflammatory joint disease

Neuromuscular disorders (hereditary motor sensory neuropathy, peroneal nerve palsy)

High body mass index

Rear foot varus

Patients describe the perception of an unstable ankle

Pain and swelling are often localized to the lateral side of the ankle (Figure 1.1)

There is avoidance of aggravating activities such as walking on uneven surfaces or certain sports

There may be coexistent peroneal tendinopathy related to an overuse phenomenon or a talar dome osteochondral lesion, giving rise to a deep-seated pain within the ankle

Altered sensation or sensitivity may occur in the anterolateral foot due to stretching of the superficial peroneal nerve after recurrent sprains

A comparative assessment of both ankles should be performed

Lower limb and hindfoot alignment must be evaluated with the patient standing

Gait should be assessed for obvious instability or antalgia

A heel raise test should be performed, looking for normal hindfoot motion from valgus to varus, which is absent in patients with tarsal coalition

Stability and proprioceptive control of the ankle may be evaluated with the patient undertaking a single-leg stance (Guillo, 2013)

Tenderness to palpation is commonly detected beneath the fibular tip and on the anterolateral aspect of the ankle

Joint motion should always be compared to the opposite side. Combined motion of the ankle and subtalar joints is evaluated by assessing the angle between the hindfoot and leg while inversion stress is applied to the calcaneum

Isolation of subtalar motion requires the ankle to be held in dorsiflexion, thereby wedging the talus in the ankle mortise. Upon hindfoot inversion the calcaneus shifts medially to the talus if there is significant subtalar instability (Colville, 1998)

Anterior drawer and talar tilt tests are performed and compared with the opposite limb for the assessment of ankle stability

Talar tilt test: the angle formed by tibial plafond and talar dome is measured applying an inversion force to the talus while stabilizing the distal part of leg with the other hand

2Assess generalized joint laxity using the Beighton Score

The clinician should also test the strength and integrity of the peroneal tendons

A neurovascular assessment of the foot is also recommended

Standard plain radiographs include standing anteroposterior, lateral, and mortise views, and a Saltzman or Meary view

Comparative stress radiographs with anterior drawer and varus tilt may be performed. Radiographs are useful to help identify contributory pathology such as bone spurs and osteochondral lesions of the talus (Colville, 1998)

When deep pain occurs suggesting an oseochondral lesion, MRI is useful to assess the grade and severity

MRI may also highlight the torn or stretched lateral ligament complex

Ultrasonography may be useful in the investigation of tendon pathology

CT or MRI-arthrography is not usually performed, but can be helpful for detailed assessment of cystic osteochondral lesions

Surgery takes place when swelling permits

Muscles and tendons of the leg should ensure adequate stability, excluding the ligamentous injury

There should be a normal range of ankle motion

It is useful to perform ankle arthroscopy before repair of the lateral ligament complex. Up to 95% of patients undergoing surgery for lateral ankle instability have associated intra-articular pathology (Ferkel, 2007)

Consider performing a simultaneous lateralizing calcaneal osteotomy for patients with hindfoot varus deformity

Arthroscope: 2.7 mm or 4.5 mm 30°-angled

Light source and cables

Camera system and monitor

Arthroscopic probe (hook)

Arthroscopic punches (basket forceps)

Arthroscopic grasper

Motorized shaver

Noninvasive ankle distractor

Gravity system or pump for instillation of 0.9% saline

Microfracture picks

Needle holder

Sutures

Scalpel, blades no. 11 and 21

Forceps: toothed tissue forceps, Adson’s tissue forceps, Kocher’s, Kelly’s and mosquito forceps

Scissors

Luer bone rongeur

Farabeuf retractors

Mini Hohmann bone elevators

Bone curettes

Hand drill

Drill guide

Kirschner (K)-wires

The arthroscopic tower is positioned on the opposite side of the ankle, at the level of patient’s contralateral hip

The open surgery equipment is positioned near the surgeon, at the same side of the ankle that is being operated

Position the patient supine with the knee extended

A well-padded tourniquet is placed on the proximal lower thigh; some surgeons may choose not to inflate the tourniquet during arthroscopy

A sandbag under the ipsilateral buttock allows improved access to both the lateral and medial sides of the ankle. The heel should be on the end of the operating table

Initially, no ankle distraction is applied and an examination under anesthetic is performed to assess stability

The patient receives a single dose of intravenous antibiotics preoperatively

The procedure is preferably performed under general anesthesia but can be performed with a regional nerve block

It is important to treat any concomitant pathology such as osteochondral lesions (Figure 1.2)

An anteromedial portal is established medial to the tibialis anterior tendon at the level of the tibiotalar joint using a ‘nick and spread’ technique

With the arthroscope in the standard anteromedial portal, the superficial peroneal nerve can be identified by directing the light source externally. The anterolateral portal is then established lateral to the peroneus tertius tendon

Noninvasive ankle distraction can be applied to the ankle to improve access, and with these portals the majority of talar dome osteochondral lesions, distal tibial bone spurs, and soft tissue impingements can be addressed

The arthroscope and any distraction should be removed from the ankle before the ligament repair commences

The surgical incision passes longitudinally for 3 cm over the distal fibula and proceeds in a J-shape with the incision turning 45° toward the talar neck. Care should be exercised to avoid cutting the peroneal tendons

Along the course of the incision there are branches of the short saphenous vein which require cautery with diathermy or ligation. It is important to avoid the lateral cutaneous branch of the superficial peroneal nerve passing anterior to the distal fibula

The peroneal tendons can be explored by extending this surgical approach. Otherwise they are retracted posteriorly, exposing the capsule (Figures 1.3 and 1.4)

The capsule–ligamentous complex along the anterior distal fibula is incised, leaving a 3–5 mm cuff on the outermost aspect of the fibula

The anterior talofibular ligament (ATFL) is identified as a slight thickening in the capsule passing horizontally toward the talar neck. 4The calcaneofibular ligament (CFL) is more distinct and is found deep to the peroneal tendons, passing downward and posteriorly towards the peroneal tubercle

The joint space underneath the fibula must be inspected to ensure that there are no soft tissue entrapments or bony avulsions that should be excised

The insertion of the ligaments on the distal fibula should be freshened by removing the periosteum of the inner distal fibula with rongeurs

The ATFL and the CFL are then plicated and reattached to the distal fibula (Figure 1.5)

After preparation of the distal fibula, two suture anchors incorporating a 2-0 nonresorbable suture are inserted into the ATFL and CFL footprints

The sutures are passed from inside to outside the capsule–ligamentous complex in the direction of the ATFL and CFL, starting distally in order to hitch up the capsule towards the distal fibula

It is advisable to place a padded kidney dish under the heel on the operating table to raise the talus anteriorly in the ankle mortise before securely tying the suture knots

As the sutures are tied, beginning with the CFL suture anchor (Figure 1.6), the ankle is held by the assistant in dorsiflexion and eversion

Multiple resorbable vertical mattress sutures can then be placed to reinforce the repair using the free cuff of fibular periosteum

It is possible to further reinforce the repair by inserting sutures from the fibular periosteum into the inferior extensor retinaculum (Gould modification)

5After the repair the ankle is gently examined for stability using the anterior drawer test and the talar tilt test

Division of the lateral branch of the superficial peroneal nerve or the sural nerve must be avoided to avoid pain from a neuroma

Branches of the lesser saphenous vein are also at risk and sacrifice of small branches may be necessary for access

After thorough irrigation with 0.9% saline, the skin incision is sutured (Figure 1.7) and Steri-Strips are applied

A pneumatic ankle brace or a light cast is applied, keeping the ankle in slight dorsiflexion and eversion

No weight-bearing is permitted during the first 2 weeks

2–6 weeks postoperatively: the ankle is placed in a removable pneumatic walking brace. The patient can increase their weight bearing and active range of motion exercises of the ankle but must avoid plantarflexion and inversion, which would stretch the repair. Passive stretching is also avoided. Swelling and edema control using an elastic compression stocking, ice, and deep tissue massage should be encouraged

6–12 weeks post-operatively: the patient can discontinue use of the pneumatic walker and can be provided with a lace-up ankle brace. Progressive resistive and proprioceptive exercises may be continued during the following 2–4 months

3 months postoperatively: running, cutting, and pivoting sports can be resumed. The brace is worn for sports for 6 months

Wound breakdown

Infection

Sural nerve injury or neuroma

Instability or recurrence

Stiffness and overtightening

Complex regional pain syndrome

Patients are assessed at 6-month intervals for 2 years and then discharged

Further examinations will be necessary only if symptoms develop again or if a new trauma occurs

A sport-specific balance training program may be effective for reducing acute-onset injuries in athletes

A history of previous lateral ankle sprain is associated with an increase in the risk of future sprain of the contralateral ankle. In order to prevent this, prophylactic protection may be helpful: a semi-rigid ankle brace is less expensive than ankle taping and offers similar results

Postural control and muscle reaction time are fundamental variables that must be considered