Lateral ankle ligament sprain is one of the most common injuries in sport (3,16,17,18,27,31). Most injuries respond to conservative treatment with a physical therapy program emphasizing proprioceptive training, restoration of motion, and strengthening of the supportive musculature (8,12,27). Surgical correction in the patient with persistent instability and dysfunction has been described utilizing a number of anatomic and nonanatomic operations (4,9,10,14,15). Many of the historic methods of ankle stabilization sacrificed some or all of an often normal peroneal tendon to achieve stability (10,14,15). These procedures typically involved weaving half of the peroneus brevis tendon to achieve stability. Disadvantages of such procedures include sacrificing a peroneal tendon, loss of motion from nonanatomical tunnel positions, large exposures with wide dissection, increased risk of nerve injury, and increased operative time (22).

More than a half-century ago, Lennart Broström published the first in a series of articles on operative treatment of lateral ankle ligament sprains (4, 5, 6, 7, 8, 9). Broström advocated direct primary repair of the lateral ligaments in patients with chronic lateral ankle instability. The operation he described was an anatomic repair formulated on the premise that the anterior talofibular ligament (ATFL) is contained in a portion of the lateral ankle capsule (4,5). He also advocated repair of the calcaneofibular ligament (CFL) when indicated. This operation restored the normal length of the lateral ligaments and respected their normal anatomical location (9). The Broström repair was advocated for the treatment of both acute ruptures and in chronic instability (4,9).

Several modifications of Broström’s original procedure have been described, the most popular being reinforcement of the primary ligament repair using a portion of the inferior extensor retinaculum sutured to the periosteum of the distal fibula (20). This adds stability to the repair, limits inversion, and helps address subtalar instability (21).

Indications for primary lateral ankle ligament repair include functional instability and chronic mechanical instability that has failed to respond to an aggressive rehabilitation program. Carefully selected professional and elite athletes may benefit from the procedure in cases of acute sprain with complete rupture of the lateral ligamentous complex. For the remainder of this chapter, the focus will be the patient with chronic lateral ankle instability.

Patients being considered for secondary lateral ankle ligament repair should have severe limitation from lateral ankle instability. This dysfunction persists despite completion of a standard rehabilitation and proprioception training program. Athletes describe giving way, frequent sprains, and inability to perform at their prior level of competition. Pain may be present, but it is generally less of a consideration than the instability. If pain is the major complaint, then other sources of pain should be investigated such as osteochondral lesions, peroneal
tendon pathology, an occult fracture, or nerve injury. Among the most frequent presentations is the athlete with a severe acute lateral ankle sprain who relates that this happens with an unnatural frequency or ease of occurrence.

In these situations, anatomic repair of the ligaments is an excellent choice for athletes because it does not restrict subtalar motion and is tendon sparing. It attempts to restore the normal anatomical length of the injured ligaments with preservation of normal anatomical origin and insertion sites along with a quick recovery and rehabilitation program.

Ankle instability can be evaluated by physical exam with talar tilt and anterior drawer tests. The talar tilt test compares inversion of the hindfoot with the contralateral ankle. The anterior drawer test stresses the lateral ankle ligaments by the examiner first stabilizing the distal tibia and then exerting a forward stress to a slightly plantar-flexed ankle (Fig. 50.1). Comparison with the contralateral side gives the examiner an idea of the degree of increased laxity in the affected ankle. The motion of the hindfoot should be observed closely during these examinations. Decreased motion in the transverse tarsal or subtalar joint could mean a tarsal coalition is present—a condition that predisposes to recurrent ankle sprain and instability.