Broström: Arthroscopic Repair

Jorge I. Acevedo and Peter G. Mangone

Abstract

Current biomechanical and clinical results indicate that arthroscopic lateral ankle ligament reconstruction is becoming an increasingly acceptable method for the surgical management of chronic lateral ankle instability. Traditional methods to stabilize the lateral ankle rely on open approaches for repair or reconstruction. The anatomy of the ATFL and capsular components of the lateral ligament complex is easily visualized during arthroscopic examination and allows for arthroscopic reconstruction techniques. We describe the indications, advantages, and key principles of an arthroscopic Broström repair technique as well as tips and pearls in order to avoid potential pitfalls. The authors have used this technique since 2007 and have published anatomic, biomechanical, and clinical data supporting the outcomes equal to traditional open techniques.

Keywords: Arthroscopy, Brostrom, lateral ankle ligament repair, ankle instability, ankle sprain

43.1 Indications

• Symptomatic chronic lateral ankle ligament instability in patients who have failed appropriate nonoperative management.

43.1.1 Pathology

• Chronic attenuation or tears of the lateral ankle ligaments resulting in recurrent inversion ankle sprains or recurrent feelings of lateral ankle instability.

43.1.2 Clinical Evaluation

• Perform complete physical examination of the ankle and hindfoot.

• Important physical examination elements:

Alignment: cavovarus foot must be corrected with lateral ankle ligament reconstruction to decrease chance of recurrence:

“Peek-a-boo” heel.

Externally rotated fibula.

Rigid plantarflexed first ray.

Motor strength/tendon assessment:

Peroneal muscle strength testing.

Tenderness possibly indicates tendon tear.

Assess for peroneal subluxation/dislocation.

Instability:

Anterior drawer test.

Talar tilt test.

Assess for subtalar instability versus ankle instability.

Palpation:

Tenderness over anterolateral ankle.

Tenderness over sinus tarsi.

43.1.3 Radiographic Evaluation

• AP (anteroposterior), mortise, and lateral ankle weight-bearing plain radiographs:

Assess for congruent versus incongruent tibiotalar alignment.

Assess for osteochondral lesions.

Assess for degenerative joint space narrowing:

If severe enough, patient may not be candidate for lateral ligament reconstruction.

Assess for exostosis:

Distal tibia—often anterolateral > anteromedial.

Talus neck—often dorsal and medial.

• Stress radiographs (as needed):

Anterior drawer.

Talar tilt.

Manual versus Telos.

• CT (computed tomography) scan:

Assess for osteochondral lesions.

Assess for intra-articular loose bodies.

Assess for degenerative changes.

Assess the anatomy of exostoses of the distal tibia and dorsomedial talus.

• MRI:

Assess for intra-articular pathology such as osteochondral lesions and loose bodies.

Assess for extra-articular pathology such as peroneal tendon tear.

43.1.4 Nonoperative Options

Physical therapy focused on proprioception, balance, and peroneal muscle strengthening.

Ankle gauntlet brace.

AFO (ankle–foot orthosis) brace (in more severe cases of ankle instability).

43.1.5 Contraindications

• Connective tissue elasticity disorder:

Ehlers–Danlos syndrome.

Marfan’s syndrome.

• Morbid obesity.

• Heavy-demand patient (relative contraindications).

• Failed previous Broström-type procedure (relative contraindication).

• History of previous failed ligament/capsular reconstruction procedures in other joints (e.g., shoulder).

• Uncorrectable varus heel deformity.

43.2 Goals of Surgical Procedure

• Reconstruct the lateral ankle ligament complex to increase stability and decrease pain.

• Return to premorbid level of activity (including sports activities) as desired.

43.3 Advantages of Surgical Procedure

• Smaller minimally invasive incision technique that has resulted in postoperative clinical course with:

Shorter operative time than current open techniques.

Decreased pain (anecdotal findings).

Decreased swelling.

Improved cosmetic appearance.

Success rate equivalent to, if not better than, published results with traditional open procedures.¹

43.4 Key Principles

• Draw out the key landmarks and safe zone prior to starting the initial arthroscopy.

• Perform an extensive debridement/clean out of lateral gutter to remove scar tissue and allow for full visualization of the anterior face of the lateral malleolus and distal tip of the fibula prior to placing the first anchor.

• After placing the first anchor, pass the sutures from that anchor prior to placing the second anchor to avoid suture entanglement.

• Pass the sutures through the skin at least 15 mm inferior to the distal tip of fibula to capture the inferior extensor retinaculum (IER) in the repair.

• Remove distraction prior to tying sutures and hold ankle/foot in neutral to slight eversion, neutral dorsiflexion, and posterior drawer force applied to the ankle.

43.5 Preoperative Preparation and Patient Positioning

Stress radiographs (either manual or with a mechanical stress device) can play a role in the decision making of whether to perform an arthroscopic repair or an open tendon augmentation type of lateral ankle ligament stabilization. MRI or CT scan may be needed to assess for additional intra-articular or extra-articular pathology such as osteochondral lesion, exostosis, and peroneal tendon tear.

A preoperative drawing of anatomic landmarks identifying the “safe zones” in the lateral ankle region is created.² The superior margins of the peroneal tendons, distal fibula tip, and intermediate branch of the superficial peroneal nerve (SPN) are outlined on the skin. The lateral calcaneal tubercle is used to identify the IER, which is located 15 mm from the fibula tip with the ankle in neutral dorsiflexion (Fig. 43.1a,b).

The patient is positioned supine on the operating room table with a well-padded tourniquet on the proximal thigh. A towel bump is placed under the ankle for distraction. Alternatively, the surgeon may elect to use a noninvasive distractor along with a thigh holder applied during positioning to keep the hip flexed 60 degrees.

43.6 Operative Technique

The arthroscopic Broström repair is typically performed under a regional popliteal block along with monitored anesthesia care (MAC). An additional block of the saphenous nerve is necessary to complete the sensory block over the anteromedial portal. General anesthesia can be used as well if the patient or surgeon prefers.

Prior to the ligament repair, standard anteromedial and anterolateral ankle arthroscopy portals are used to perform the initial diagnostic arthroscopy and treat any concomitant intra-articular pathology. A thorough debridement of the lateral gutter is also necessary in order to clearly visualize the anterior face of the fibula and avoid impingement of anterolateral tissues. All borders of the distal fibular tip should be probed and the anterior fibular face should be denuded in order to improve tissue adherence.

Using the standard anteromedial portal for viewing the lateral ankle joint, the first bone anchor is drilled and inserted, through the standard anterolateral portal, 1 cm superior to the distal tip of the fibula (Fig. 43.2). This location corresponds with the inferior origin point of the ATFL on the anterolateral malleolus. The sutures are brought out through the anterolateral portal and then shuttled with a sharp-tipped suture passer (using either an “inside-out” or outside-in” technique) through the lateral ligament complex exiting the skin within the safe zone. The first suture limb is passed just superior to the peroneal tendon margin, while the second suture limb is passed 1 cm dorsal/anterior to the first suture following the arc of the IER (Fig. 43.3).

Once the first set of sutures is passed, the second anchor is drilled and inserted 1 cm above the first anchor (usually just below the level of the talar dome) on the anterior face of fibula (Fig. 43.4a,b). The second set of sutures is brought out through the anterolateral portal and shuttled, similar to the first suture set (using either an “inside-out” or outside-in” technique), along the arc of the IER with both suture limbs spaced 1 cm apart (Fig. 43.5). Care is taken to assure the exit points are inferior to the intermediate branch of the SPN and within the safe zone.