More than 70 operative procedures have been described in the literature for treatment of chronic lateral ankle instability. These lateral ankle reconstructions can be broken down into anatomic and nonanatomic procedures. Anatomic procedures are further divided into primary repair (Brostrom) versus allograft or autograft reconstruction. Nonanatomic procedures involve tenodesis procedures with rerouting of a tendon (Watson-Jones). Anatomic procedures are beneficial because they restore as close as possible the normal anatomy and joint kinematics, as well as maintain ankle and subtalar joint range of motion. Unfortunately, primary anatomic reconstruction is not always a viable option due to poor tissue quality, and it relies on the ability to tension ligaments appropriately and the security of fixation. Anatomic reconstruction with a Brostrom procedure was first described in 1966 with repair of the anterior talofibular ligament [10–12]. Many modifications have been made to this procedure over the years, most notability the Gould modification in 1980 with the addition of repair of the calcaneofibular ligament and reinforcement with inferior extensor retinaculum [13]. The Brostrom procedure with Gould modification has become the standard for primary lateral ankle stabilization. In this technique the ATF and possibly CF ligaments are primarily repaired and reinforced with the inferior extensor retinaculum. When Brostrom first described the repair, it was a direct repair of the AFTL and CFL with imbrication of the ligaments to decrease any laxity from previous injury. The Gould modification with the reinforcement with the inferior retinaculum was adopted due to concerns of inadequate tissue quality. Multiple studies have found the Brostrom-Gould procedure to be extremely effective with good to excellent outcome in greater than 85% of patients [1, 4, 6, 8–17]. Nonanatomic repair consists of adding structural support to the ankle perpendicular to the perceived axis of instability. The first documented procedure of Watson-Jones in 1952 utilized the entire peroneus brevis tendon and routed in through the fibula from posterior to anterior and then secured in the tendon into the talar neck [18]. Multiple other nonanatomic repairs have been described utilizing allografts and autogenous grafts, most commonly the peroneus brevis tendon. These procedures should be reserved for patients with generalized ligamentous laxity and salvage procedures.

Hennrikus et al. compared anatomic to nonanatomic and found similar success rates around 85% but higher complication rate with nonanatomic, consisting of sural nerve damage, wound complications, stiffness, and residual instability [19]. Brostrom had no wound complications but did have superficial peroneal nerve paresthesias, stiffness, and one repeat rupture. Krips et al. reviewed 300 patients over 30-year follow-up and found initially no difference but nonanatomic correlated with increased rate of decreased function, increased pain, stiffness, increased reversional procedures, and increased arthritis [1].

Multiple exposure techniques have been described for the Brostrom-Gould procedure. The standard approach consists of an approximate 4 cm curvilinear incision over the distal anterior aspect of the fibula (Fig. 27.2). This incision can be utilized to visualize the course of the peroneal tendons extending anteriorly around the distal tip of the fibula. Dissection is taken down to the underlying inferior extensor retinaculum; during this part of the dissection, you may encounter a focal area of adipose tissue, especially in the female population. A moist sponge is helpful at this point to help with blunt dissection to identify the inferior retinaculum. The retinaculum should be seen parallel to the CFL and mobilize and reflect this layer (Fig. 27.3). The ATFL and CFL can be visualized at this time as thickened fibers of the capsule. Make a capsular incision along the anterior aspect of the fibula to the distal tip, leaving a few millimeters attached to the fibula to facilitate repair. Nonabsorbable suture 2-0 or larger is passed through the ATFL and CFL, and the foot and ankle are held in an everted valgus position while sutures are advanced (Fig. 27.4). The previously reflected inferior extensor retinaculum is sutured to the anterior edges of the fibula. Subcutaneous and cutaneous closure is done in standard fashion. Special care must be taken, and a good assistant is needed to maintain the foot in the everted valgus position during the remainder of the procedure and during cast or splint application. Standard protocol consists of non-weight bearing in cast for 6 weeks, but there is literature that supports accelerate rehabilitation protocol results in faster return to sport. Petrera et al. advocated immediate protective weight bearing in a walking boot and early range of motion to promote recovery of proprioception and decrease stiffness and muscle atrophy [4]. They found in their study a return to sport 3 weeks faster with accelerated rehabilitation protocol.

As with any procedure, there is risk for complications which may occur intraoperatively, immediate postoperatively, and late onset. To help limit these complications, a thorough patient workup is necessary, and assessing other problems at the time of the procedure is imperative. The patients with long-standing instability, poor tissue quality, generalized ligamentous laxity, and structural deformity are patients that are more prone to complications. Superficial wound complications and neuritis are the most common complication which can occur in up to 7–19% of the cases [1–3, 8, 10–14, 19, 20]. In these cases meticulous surgical dissection and tissue handling are imperative. Overcorrection and undercorrection need to be taken into account, and a good assistant is beneficial to hold the foot in the corrected position during repair. Stiffness and overcorrection are common in both anatomic and nonanatomic repairs but more common in the nonanatomic group.

Recurrence and postoperative instability are normally secondary to acute injury. Petrera et al. reported a 6% failure rate with 3 out of 49 patients re-rupturing secondary to traumatic inversion ankle injuries during sporting events [4]. These patients were treated conservatively and did not require reversional surgery. If implementing an accelerated rehabilitation protocol, the patient should be protected in the initial postoperative period to help decrease risk of repeat traumatic rupture. In the case of a repeat rupture or undercorrection, salvage procedures with anatomic augmented tenodesis reconstructions are always a viable option for repair.

The first step in limiting complications is being familiar and acknowledging the contraindication and limitations of the different procedures. Limitations of these procedures start with patients with morbid obesity, previous documented arthritic changes of the subtalar or ankle joint, and subtalar joint inability and patients with collagen disorders . Contraindications consist of patients with progressive neuromuscular disorders, tarsal coalitions, and complex regional pain syndrome.

Most complications with the Brostrom procedure can be avoided during the preoperative assessment of the patient. When evaluating patients preoperatively, instead of looking at patient factors that would indicate a successful outcome, the authors prefer to evaluate patient factors that would lead to an unsuccessful outcome with a Brostrom. Does the patient have a large BMI, or do they have a job that requires a high amount of stress on the ankle? Do they have a varus position of their heel, a cavus foot, or have weakness of the peroneal muscles? One of the more often overlooked issues is recognizing patients with hypermobility syndromes such as Ehlers–Danlos syndrome (Fig. 27.5). These types of conditions often have poor tissue quality that will require surgical augmentation in order to be successful. If the answers to these questions are negative, then the success rate of a Brostrom procedure is high.

On physical examination, make sure that pathologic joints have been identified. Radiographic stress exam can be utlilzed. To improve accuracy of the stress exam, eliminate the tension on the peroneal tendons either through use of sedation or local anesthetic. Also, pay attension to any instability of the subtalar joint during the exam. Intra-articular injections of the ankle serve as a strong diagnostic tool. Evaluate both the ankle joint and subtalar joint for arthritic conditions.

As previously mentioned, there is a high correlation between chronic lateral ankle instability and intra-articular pathology, and the addition of ankle arthroscopy is often beneficial. If an arthroscopic procedure is scheduled, it is a good practice to mark out bony landmarks and incision site for the lateral ankle stabilization prior to the arthroscopic procedure, as extravasation of fluid with the arthroscopy may obscure exact boney anatomic landmarks making them difficult to palpate and therefore altering incision placement.