Jefferson Sabatini and Robert B. Anderson

Abstract

Anatomic repair of the lateral ankle ligament complex of the ankle for chronic recalcitrant ankle instability was first described by Broström in 1966. Since then, there have been numerous modifications and improvements to this technique including augmentation utilizing the inferior extensor retinaculum (Gould’s modification), or a split portion of the peroneus brevis tendon (Evans’ procedure), as well as utilizing suture anchors to assist the reattachment into the fibular and newer arthroscopic-assisted techniques. This chapter outlines the indications and technique of performing the Broström–Evans procedure, including tricks to optimize results and avoid complications.

Keywords: ankle instability, ankle ligament reconstruction, Broström, Evans, split peroneus brevis, technique

42.1 Indications and Pathology

• Chronic lateral ankle instability:

Functional: subjective feeling of instability or recurrent symptomatic ankle sprains.

Mechanical: ankle motion/laxity beyond the physiologic range.

• Patients that fail 3 to 6 months of conservative management and continue to have symptoms of functional or mechanical ankle instability are candidates for lateral ligament reconstruction.

42.1.1 Clinical Evaluation

• The patient’s clinical history and physical examination are key to the diagnosis of lateral ankle instability. Patients usually present with a subjective history of the ankle giving away or the feeling that it might. Occasionally there is pain associated with instability but that may be due to concomitant intra-articular issues. Upon questioning, the patient will often report a history of an ankle sprain or inversion injury at some point in the past. It is not uncommon for this event to have occurred a long time before presentation. The duration of symptoms, frequency of sprains, and previous physical therapy or bracing are important determinants for future treatment.

• The physical exam for lateral ankle instability begins with inspection of the patient’s standing alignment. A varus hindfoot or ankle alignment can place the patient at increased risk for inversion injuries. A plantarflexed first ray may also precipitate this varus tendency.

• Palpate the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and syndesmotic ligaments. One should also palpate the peroneal tendons, medial and lateral malleoli, anterolateral dome of the talus, sinus tarsi, lateral process of the talus, and anterior process of the calcaneus to rule out other potential pathologies of lateral ankle pain.

• Anterior drawer and talar tilt testing are the main provocative physical exam maneuvers for lateral ankle instability. The anterior drawer test is when the talus is translated anteriorly in respect to a stabilized tibia. It is aided with the addition of internal rotation. With the deltoid intact, this becomes a rotational movement about the medial malleolus center of rotation. As the ATFL is the primary restraint to anterior translation when the ankle is in planter flexion and the CFL is the primary restraint in neutral, anterior drawer testing in these positions can give information as to which structures may be incompetent. Greater than 10 mm of translation, or 5-mm translation greater than the contralateral side, is considered to be positive. Talar tilt testing is performed by inverting the heel with respect to a stabilized tibia with the ankle and subtalar joint in a neutral position. Any gross difference compared to the contralateral side or soft end point would be suspicious for CFL laxity.

42.1.2 Radiographic Evaluation

• Imaging is important for ruling out other sources of lateral ankle pain, and should be used as an adjunctive to the history and physical examination.

• Obtain weight-bearing anteroposterior (AP), mortise, and lateral images of the affected ankle to look for signs of osteochondral lesions or tibiotalar arthrosis, as well as the overall alignment of the ankle and hindfoot.

• Anterior drawer and talar tilt tests can be quantified using stress radiography. Anterior translation of the talus in a lateral radiograph 10 mm, or 5 mm greater than the contralateral side, is considered positive. Talar tilt stress testing 10 or 5 degrees greater than the contralateral is considered significant. Stress fluoroscopy can also be performed and may be helpful in identifying asymmetries, assuming the patient is relaxed.

• Ultrasound examination can be useful in the setting of potential peroneal pathology as a dynamic examination can reveal tendon subluxation.

• Computed tomography (CT) can provide accurate information about osteochondral lesions of the talus, as well as underlying tarsal coalitions and nonunion of the lateral process of the talus and anterior process of the calcaneus. Weight-bearing CT can also show subtle syndesmotic widening compared to the contralateral side.

42.1.3 Nonoperative Options

• Physical therapy for proprioception and peroneal strengthening is the mainstay of nonoperative treatment for chronic ankle instability. At least 6 weeks of physical therapy should be completed before surgical intervention is indicated.

• Ankle braces, such as the “lace-up” variety, provide external ankle stability and can be worn inside of shoes. An ankle–foot orthosis (AFO) or double upright brace can also be used to stabilize the ankle.

42.1.4 Contraindications

• Low-demand patients or those with significant medical comorbidities should be treated nonoperatively with bracing.

• Generalized ligamentous laxity as seen in conditions such as Ehlers–Danlos syndrome is a contraindication to isolated anatomic ligamentous repair, and typically requires a reconstruction enhanced with autograft, allograft, or suture tape.

• Patients with a varus hindfoot alignment should undergo correction of their alignment with a lateralizing (or Dwyer-type) calcaneal osteotomy and/or dorsiflexion first metatarsal osteotomy with reconstruction of their lateral ligaments to prevent recurrence of ankle instability.

• Athletes who require extensive plantar flexion and preservation of inversion such as en pointe in ballet dancers should not undergo the split Evans augmentation to the Broström procedure.

42.2 Goals of Surgical Procedure

• Repair and reconstruct the major static stabilizers of the lateral ankle (AFTL and CFL).

• Re-create a stable ankle mortise during physical activity.

• Prevent future lateral ankle sprains.

• Diminish the risk of degenerative arthritis associated with recurrent ankle sprains.

42.3 Advantages of Surgical Procedure

• Ability to visualize, evaluate, and manage concomitant peroneal tendon pathology.

• Direct visualization of the ATFL, CFL, and inferior extensor retinaculum.

• Direct exposure of the ATFL into the fibular allowing bony preparation for the reattachment of the ligament.

• Allows utilization of a portion of the peroneus brevis tendon to augment the reconstruction.

42.4 Key Principles

• Initial arthroscopic evaluation of the ankle to exclude or manage any intra-articular pathology.

• Advancing the ATFL back into a decorticated bony bed at the fibular insertion.

• Plicating the CFL with “box” sutures to tighten the ligament.

• Augmentation of the repair utilizing the anterior one-third of the peroneus brevis tendon, secured with an interference screw in a fibular tunnel between the insertional points of the ATFL and CFL.

• Addition/optional augmentation of the repair utilizing the proximal aspect of the inferior extensor retinaculum (Gould’s modification).

42.5 Operative Technique

It is the preferred technique of the author to add the split Evans procedure (tenodesis of the anterior 30% of the peroneus brevis tendon to the fibula) to most Broström procedures for added restraint to ankle inversion.

42.5.1 Positioning

• If ankle arthroscopy is going to be performed concomitantly, the patient will need to be supine with the leg in an arthroscopy leg holder.

• Lateral ankle ligament reconstruction can be performed supine with a bump under the ipsilateral hip, overly bumped to produce the so-called sloppy lateral position.

• It is the author’s preference to perform the procedure supine with a bump, especially if any concomitant procedures are being performed.

42.5.2 Surgical Approach