29.1 Introduction

The Brostrom procedure, originally described in 1966, ¹ has been a mainstay surgical treatment for lateral ankle instability secondary to ATFL insult. The ATFL functions to prevent anterior translation of the talus within the talocrucal joint. This intra-capsular ligament, spanning from the anterior margin of the lateral malleolus to the anterior margin of the lateral talar body, is most commonly attenuated in inversion ankle injuries. Although studies suggest that proprioceptive training might restore native function to the intact lateral collateral ligament, often a chronically torn ATFL is left wanting. Historically, direct end-to-end repair of the ligament provided favorable short-term outcomes. Gould described a technique harvesting a portion of the extensor retinaculum to reinforce the direct repair.

MRI is highly sensitive in diagnosing ATFL pathology, ² and is useful for identifying concurrent CFL injury, as well insult to the peroneal tendons. MRI can also be helpful in identifying osteochondral lesions of the talus and tibial plafond. Nonetheless, if surgical repair of the ATFL is warranted, we recommend the implementation of arthroscopy to rule out intra-articular lesions. ³ Moreover, we utilize an incisional approach that allows scrutiny of the peroneal tendons and retinaculum, and the CFL.

The modification to the Brostrom we favor implements anchored suture tape to recreate the ATFL with the supplementation of adjacent suture anchors to repair the native tissue. ^{4 , 5} Anchored suture tape can also be utilized if direct CFL repair is warranted.

29.2 Preop

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  Positioning. The patient is placed supine on the surgical table with a bump under the ipsilateral hip to internally rotate the ankle and foot just passed perpendicular. This position allows direct visualization of the anterolateral ankle and facilitates assessment of the posterior lateral ankle. If arthroscopy is being performed, we recommend a thigh holder to facilitate joint distention, with or without the joint distractor. If a thigh hold is unavailable, the patient can be positioned with the ankle distal to the bed. Slight internal rotation of the elevated ankle also allows for easy placement and utilization of the anteromedial, anterolateral, and posterolateral arthroscopic portals. A sterile bump can be made with surgical towels during the surgical repair to insure appropriate position of the talus.

  
  
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  Tourniquet. Its use is based on surgeon preference, and when used, is best placed at the thigh level. Conversely, hemostasis with anatomic dissection and electrocautery is not particularly painstaking in this area.

  
  
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  Anesthesia. Laryngeal mask airway or general endotracheal anesthesia is the method of choice, particularly if arthroscopy is being utilized. Monitored anesthesia care with regional or local blockade has been described.

  
  
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  Joint insufflation. Lidocaine with epinephrine is utilized as needed to augment joint distraction and minimize intra-articular bleeding intraoperatively. Additionally, epinephrine can be combined to the ingress fluid bag to improve visibility. Portal placement should be drawn prior to insufflation, and after extremity exsanguination.

29.3 Approach

Surgical landmarks are demarcated with a surgical marking pen prior to joint insufflation. The arthroscopy portals are mapped, medial to the tibialis anterior tendon, lateral to the peroneus tertius tendon and between peroneal tendons and Achilles tendon posteriorly, approximately 2-cm proximal to the fibula. It is prudent to identify the pathway of the superficial peroneal nerve and sural nerve so as to avoid complication in placing the antero- and posterolateral portals, respectively. The procedural details of ankle arthroscopy are describe elsewhere in this text.

29.3.1 Modified Brostrom—Incision and Dissection

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  Approximate 8-cm incision is made in superficial fashion with a #10 surgical blade starting from the posterior border of the lateral malleolus extending distally and anteriorly to the area overlying the base of the 4th metatarsal (▶Fig. 29.1).

  
  
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  Blunt dissection with a tenotomy scissors is performed down to the adventitial layer overlying the tendon sheath posterolaterally and through the overlying adventitial layer overlying the sinus tarsi distally.

  
  
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  Within the distal portion of the incision, subcutaneous fat is bluntly mobilized dorsally down to extensor retinaculum within the sinus tarsi. Utilize a freer elevator to develop a layer deep to the retinaculum to isolate and mobilize (▶Fig. 29.2). This is an important step in preparation for retinaculum augmentation.

  
  
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  Attention is then directed to the distal fibula and the articulation with the lateral talar process. Establishing the anterodistal border of the fibula, utilize a freer to bisect the soft tissue between this landmark and the neck of the talus distally. The orientation of the freer should be inserted from plantar distal to dorsal proximal along the curvature of the anterodistal margin of the fibula, and should be intracapsular. With a #15 surgical blade, sharply incise the overlying capsular soft tissue and native remnants of the ATFL ligament deeply into the joint. Be sure to leave enough residual soft tissue and ligament remaining off of the fibula. This will provide a cuff of tissue for soft tissue augmentation. If arthroscopy has been performed prior, the extravasation of joint fluid will be appreciated with this incision.

  
  
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  At this point, the talofibular articulation should be readily visible, along with access to the neck of the talus.

Related posts:

28 Ankle Arthroscopy 30 Achilles Tendon Repair 31 Hallux Valgus Surgery 14 Component Positioning in Hip Arthroplasty 19 Hip Arthroscopy 34 Femoral Rotational Osteotomy

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