What Is A Brostrom Repair
Curr Rev Musculoskelet Med. 2022 Dec; xiii(6): 788–796.
Open Brostrom for Lateral Ligament Stabilization
Kenneth J. Chase
Department of Orthopedic Surgery, University of Colorado, Aurora, USA
Rebecca Griffith
Section of Orthopedic Surgery, University of Colorado, Aurora, U.s.
Abstract
Purpose of Review
Lateral ankle ligament sprains are 1 of the well-nigh commonly reported injuries in loftier-level athletes and the general population. Unfortunately, upward to xl% of these can go along to develop chronic lateral ankle instability which in the right circumstances requires surgical intervention. The purpose of this review is to present the gilt standard surgical treatment for chronic lateral instability with anatomic ligament repair and to highlight the techniques, outcomes, and importance of anatomy when because surgical treatment.
Recent Findings
Recent and remote literature agrees that the initial handling for chronic ankle instability is not-operative rehabilitation. In the cases where this fails, the gold standard of surgical treatment is open anatomic repair using the Brostrom-Gould technique which stands out as having very good results over the course of time. Recent studies accept shown equally good outcomes with arthroscopy equally well as with internal brace devices, and both techniques show potential for earlier rehabilitation. In those with contraindications for anatomic repair including innate soft tissue laxity, loftier BMI, and in the revision setting, anatomic ligament reconstruction is an appropriate surgical option.
Summary
Open modified Brostrom lateral ligament repair continues to be the preferred method of surgical handling for chronic lateral ligament instability. In the setting of new modifications and techniques, long-term consequence studies are necessary to identify both their usefulness in long term and to compare them to the open surgery outcomes. It would exist useful to standardize rehabilitation protocols besides as render to sport metrics in order to better evaluate outcomes moving forward.
Keywords: Brostrom, Talocrural joint instability, Lateral ligament repair, ATFL, Ankle sprain
Introduction
Ankle sprains remain one of the most usually reported musculoskeletal injuries and occur across a wide variety of activities and sports [1, 2•]. Acute ankle sprains are generally the issue of an inversion or eversion injury. Sprains of the lateral ligament complex are the most common [1]. Lateral ligament sprains are the almost ordinarily reported injury in collegiate athletes in the USA [2•]. Initially, lateral ankle sprains tin be successfully treated conservatively with rest, ice, non-steroidal anti-inflammatory drugs, and early on mobilization [3•, 4]. Those with astute ankle instability do good from a flow of rest followed by functional rehabilitation to provide the strength and conditioning needed to return to sport or activities [3•, 5]. At that place is evidence that functional rehabilitation and bracing can preclude farther instability events; however, 20–40% of patients diagnosed with acute ankle instability volition go on to develop chronic ankle instability (CAI) [5–vii].
CAI is diagnosed when patients present with recurrent ankle instability events, apprehension with activities oftentimes including ambulating over uneven surfaces, and ankle joint pain [6, 8, 9, 10•]. Bracing is unlikely to completely resolve their symptoms. Mechanical instability is more often than not acquired past ligamentous rupture or laxity after an initial ankle sprain or as a culmination of multiple sprains. Targeted physical therapy with remainder and strength training can address functional instability resulting from proprioceptive and strength deficits [11•]. If chronic instability is diagnosed and fails bourgeois therapies, it is more than likely secondary to anatomic insufficiency. The almost common surgical handling for mechanical CAI that has failed functional rehabilitation is surgical anatomic repair or reconstruction of the lateral ligament complex [7]. Chronic painful instability of the ankle can lead to osteochondral lesions, synovitis, and post-traumatic arthritis if left untreated [12, 13].
In the setting of chronic lateral ankle instability, multiple surgical techniques have been described. The best outcomes historically have been seen with the ATFL primary repair technique described by Brostrom in 1966 and that technique'due south subsequent modifications [14]. While at that place are many new techniques in the literature involving arthroscopic modifications, the excellent long-term outcomes for the open up procedure ensure its electric current condition as the gilded standard of surgical care for chronic ankle instability. The purpose of this article is to review the current literature on the widely used open modified Brostrom technique for the surgical management of lateral ankle instability. We will also draw the technique in item.
Anatomy and Injury Mechanism
Lateral ankle instability presents meaning morbidity for those who fail non-operative interventions, and a articulate understanding of the beefcake of these ligaments is paramount to the surgical management of these patients. There are 3 distinct ligaments which provide stability to the lateral ankle including the anterior talofibular, the calcaneofibular, and the posterior talofibular ligaments.
The inductive talofibular ligament (ATFL) functions to limit anterior translation of the talus as well every bit excessive plantarflexion and inversion of the talocrural joint. The ligament is most decumbent to injury when the ankle is in a plantarflexed position with an inversion moment and is the well-nigh frequently injured ligament during an ankle sprain. It originates on the anterior aspect of the lateral malleolus approximately 10 mm proximal to the fibular tip and continues anteromedially to its insertion betoken on the lateral talar body just anterior to the talofibular component of the ankle joint [15, sixteen]. The ATFL is most commonly composed of one or two divide bands with a close clan to the joint capsule and is placed on the greatest tension in a plantarflexed and inverted position which is consistent with the mechanism of injury to this ligament [15, 17].
The calcaneofibular ligament (CFL) spans from the inductive distal fibula to the posterolateral calcaneus running in an anterior to posterior direction [16]. Upon initial surgical autopsy, only approximately 1 cm of the ligament is visualized since information technology is located deep to the peroneal tendons [15]. The CFL is the only lateral ligament that spans both the talocrural and subtalar joints, and it functions in stabilizing both the talocrural and subtalar joints under multidirectional loads [18••]. Information technology is the principal restraint during an inversion moment [19]. Injuries to this ligament near commonly occur with a concomitant ATFL tear and are extremely rare in isolation [20].
Finally, the posterior talofibular ligament (PTFL) runs in a horizontal design from the medial distal fibula to insert on the posterolateral talus. The PTFL is placed on tension during dorsiflexion and is rarely injured in an ankle sprain nor has it been constitute to contribute to talocrural joint instability in isolation. Injuries to the PTFL generally just occur in loftier energy ankle injuries and are only identified in five–x% of talocrural joint sprains. Complete injuries to PTFL are more than likely equally a result of talar dislocation [21]. Due to these findings, the PTFL does not usually require surgical repair and is not function of the Brostrom technique for ankle instability [fifteen].
Evaluation and Diagnosis
Patients presenting with CAI consistently report a sensation of ankle instability over a long period of time. Initial evaluation must include a detailed history including prior injuries, history of multiple instability events, and any previous surgeries. Multiple ankle sprains, elevated BMI, female gender, intrinsic foot or talocrural joint deformity, and generalized ligamentous laxity are all factors that can predispose patients to CAI [10]. Those with poor dynamic control and irksome recovery to previous function following an acute lateral ankle sprain are at higher risk for developing CAI [22].
Evaluation of patients with CAI should include a typical exam of the foot and ankle with exam of the contralateral extremity utilized as the "normal" control. Initially, inspection of alignment, deformity, swelling, or areas of point tenderness should be addressed. On concrete exam, it is important to observe the alignment of the foot and talocrural joint as hindfoot varus is a known take chances gene for CAI and lateral ligament instability [23, 24]. In the cavovarus foot, the vector of pull of the Achilles tendon at heel strike causes increased stress in the lateral ligamentous structures, placing them at risk for failure during an inversion moment [24]. Ligament competency is evaluated using the anterior drawer test for the ATFL and talar tilt examination for the CFL. The neurovascular status should be carefully evaluated as proprioceptive deficits and peroneal weakness can contribute significantly to the development of CAI. It should exist noted that physical exam findings, especially when related to laxity, must be viewed as a whole. At that place is no single test for the diagnosis of CAI [25, 26•].
Imaging
Every bit with nigh orthopedic evaluations, plain radiographs are important when evaluating CAI. Typically these are performed with the subject weight bearing. Identification of deformity or evidence of old avulsion fractures can provide valuable details for surgical planning. Stress radiographs tin can also be utilized in identifying pathologic instability which leads to alterations in the talar tilt or in anterior talar translation on the tibia. This test can be performed under x-ray or alive fluoroscopic test. The resulting images can ostend the diagnosis of ankle, and subtalar, instability, and aid in surgical decision-making. Pathologic instability is typically diagnosed with talar tilt greater than 6 degrees and anterior translation greater than 5 mm [27]. While stress radiographs are an cheap and straightforward exam to perform, a positive test does not necessarily correlate with a difference in patient outcome scores after an open up Brostrom procedure; even so, they can exist helpful in differentiating office and mechanical instability [28].
In situations where physical exam is ambiguous, MRI and ultrasound can be employed to diagnose ATFL and CFL tears in a non-invasive manner [29•] (Fig.ane). MRI is frequently utilized to identify co-existing intra-articular pathology prior to surgical intervention (Fig.ii) equally the treatment of osteochondral lesions, for example, will alter the postoperative rehab protocol. While this tin be helpful, arthroscopy remains the gilt standard for identification of osteochondral lesions, loose bodies, tendinopathy, and additional ligamentous injuries when compared to MRI [30•].
CFL tear with osteochondral lesion of the talar dome on MRI
Surgical Technique
The technique initially described past Brostrom included the anatomic repair and imbrication of the ATFL too as the CFL when needed. Gould has since modified the technique with the employ of the extensor retinaculum as an additional reinforcement repaired superficially to the main repair of the CFL and ATFL [31]. While techniques can vary past surgeon, the general principles for open Brostrom-Gould anatomic repairs for lateral ankle ligament instability remain consistent.
The following is the technical description of the writer'southward preference when performing open lateral ligament repairs. The patient is positioned in a supine position with a crash-land under the ipsilateral hip, and full general anesthesia can be used. A tourniquet is placed on the proximal thigh, and perioperative antibiotics are administered. If arthroscopy is indicated prior to open repair, an ankle distractor is applied (GUHL (Smith & Nephew) or other), and the superficial peroneal nerve is identified and marked. Standard anteromedial and anterolateral arthroscopic portals are established for exam of the joint. Post-obit intra-articular exam and identification of any intra-articular pathology needing to be addressed, the open portion of the example begins. A curvilinear incision is made over the distal fibula and extending inferiorly towards the sinus tarsi. This incision allows access to both the ATFL and CFL for repair. If peroneal tendon pathology is present, the incision can be moved more posteriorly for better access to those tendons. Autopsy is carried downward through the skin and subcutaneous tissue exposing the anterolateral joint capsule as well as the inferior extensor retinaculum. Care is taken to avoid damaging any branches of the superficial peroneal nerve. The inferior extensor retinaculum is mobilized and protected inferiorly, while the peroneal tendon sheath is retracted posteriorly to access the CFL.
The ATFL footprint is incised at the distal fibula, and the ATFL ligament is isolated distally. The proximal periosteum is elevated (Fig.3). A rongeur is used to decorticate the surrounding bone to promote healing. If CFL laxity is suspected from pre-operative examination and this is correlated in the operating room, the CFL can be directly repaired in a pants over vest mode with suture or a suture anchor that can be drilled and placed in the CFL fibular footprint and the ligament stump advanced to the fibula. The ATFL footprint on the distal tibia is then exposed with subperiosteal dissection. The authors' preference is to drill and place one or two suture anchors into the ATFL footprint on the distal fibula. (Information technology is also possible to perform the repair with 2–iii pants-over-belong sutures). The ATFL is repaired to the footprint using 2 pants-over-vest sutures from inferior to superior. Kickoff, the sutures are passed through the ATFL ligament (Fig.iv). Next, they are passed underneath the periosteum exiting superficially (Fig.5). The repair is over-sewn with 0 Vicryl suture to reinforce the ligament repair. The inferior retinaculum is then advanced over the ATFL repair and sutured to the remaining periosteal flap proximally (Fig.6). During the repairs of both ligaments, information technology is important that the ankle is held in neutral with full eversion. The subcutaneous and skin layers are airtight in the standard layered technique, and a sterile dressing is placed. A well-padded three-way short leg plaster splint with advisable neutral talocrural joint position is applied.
Tibial ballast placed for ATFL repair
Repair of the ATFL to tibial anchor (author'due south preferred technique for operative open lateral ligament repair)
Repair of the ATFL to tibial ballast with ligament imbrication and periosteal reinforcement (author'south preferred technique for operative open up lateral ligament repair)
Repaired ATFL (author's preferred technique for operative open lateral ligament repair)
The classic Brostrom-Gould technique does not employ suture anchors only rather utilizes suture imbrication and repair of the ATFL and CFL in a pants-over-vest fashion with subsequent inferior retinacular reinforcement [31]. In cases where bereft retinaculum is present for repair secondary to attrition of the tissues or anatomic variance, ligament repair can successfully exist undertaken without reinforcement [32, 33].
Postoperative Rehabilitation
As in all other orthopedic procedures, adherence to a postoperative protocol is paramount to the success of a surgery for any patient. Following anatomic repair for chronic lateral ankle instability, the good author's preferred rehab protocol includes 2 weeks of non-weight bearing in a splint or brace with talocrural joint in neutral dorsiflexion. For the following 4 weeks, weight bearing is immune in a kick or caryatid. Range of motion (ROM) and strengthening are advanced between weeks four–6 with absolutely no inversion, in order to protect the repair. ROM is continued with an emphasis on proprioceptive work for an additional 2 weeks, ensuring that inversion remains restricted throughout. Patients are placed in a lace up ankle brace for this phase of recovery. ROM with limited inversion, strengthening, and proprioceptive training are continued until 10 weeks at which fourth dimension patients are allowed to return to total ROM and work towards return to sport-specific metrics after approximately 12–16 weeks.
Most modernistic rehabilitation programs call for like early mobilization and range of motion depending on the force of the ligamentous repair [34]. For lateral ligament repairs, it is generally accepted that the patient will be non-weight begetting for 7–ten days in a splint or boot for immobilization. From surgery to 6 weeks postoperatively, rehabilitation consists of slowly increasing range of motion with restrictions on plantarflexion and inversion in lodge to protect the ligament repair. In improver to range of movement, strengthening of dorsiflexion and eversion with emphasis on gait training is likewise encouraged. At 6 weeks postoperatively, range of motion is no longer restricted and proprioceptive, and balance are emphasized. A walking kicking is employed until gait and rest are restored. Return to sport is not allowed until individuals can demonstrate 90% of pre-injury levels of force, proprioception, and residuum. Athletes must also meet sport-specific metrics that must be passed prior to return to sport [34, 35].
In that location is show that immediate postoperative weight begetting does non alter the outcomes of lateral ligament repair when range of motion was restricted [36]. In the protocol described past Petrera et al., initial ROM was restricted but weight begetting as tolerated was allowed in a boot. Range of motion was progressed during the 3rd week postoperatively with full progression to active range of motility in all planes at 6 weeks. Strength, proprioception, and gait training were incorporated throughout the rehabilitation procedure. There was a 6% failure rate in this group which is comparable to the failure rate reported in other outcome studies for the modified Brostrom repair [36]. Return to play tends to be faster in the elite athlete population as they start off at a higher level of fettle and take access to physical therapy and other modalities that the general public may not be afforded. The average time to render to play is by and large greater than iv months post op, but this has been reported earlier in the athlete population [35, 37••]. Unfortunately at that place is a paucity of literature regarding standardized return to sport data [38••].
Surgical Techniques and Outcomes
The open Brostrom procedure for lateral ligament incompetency remains the golden standard for the surgical treatment of CAI. Outcome studies since the original introduction of the modification take shown splendid results [31, 39, xl••]. As techniques utilizing arthroscopy as well equally anchors and suture reinforcement are oft being utilized, in that location are multiple studies comparing and contrasting the outcomes of these new and modified techniques to the open Brostrom-Gould technique. Many surgeons are now utilizing anchors to reinforce the imbrication and repair described by Brostrom-Gould. Rigby et al. plant no significant divergence in outcome when comparing their modified Brostrom-Gould which included anchor reinforcement at the distal terminate of the fibula to an all within arthroscopic repair of the ATFL. There was no significant difference in outcome noted despite differences in intra-articular pathology likewise as postoperative rehab protocol in the two different groups. The arthroscopic repair group was allowed to weight bear earlier than the open up group. At that place was a rate of 97% return to activities including sport for athletes across both groups [41].
When it comes to the open versus arthroscopic Brostrom-Gould techniques, both have first-class patient outcome scores regardless of which technique is used [40••, 42•]. Nevertheless, in that location is a slightly higher reported reoperation charge per unit in the arthroscopic group [43•]. It is of import to also consider concomitant pathology at the fourth dimension of ligament repair every bit the literature reports a rate of greater than 50% [44]. A contempo retrospective report looking at arthroscopic evaluation and treatment of intra-articular pathology at time of lateral ligament repair or reconstructive surgery did issue in fewer talocrural joint arthrodesis cases as well as less wound complications when compared to the lateral ligament procedure solitary. It should be noted that arthroscopy did not decrease the overall reoperation charge per unit [44].
Biomechanical studies comparison the arthroscopic versus open modified Brostrom also showed no departure in torque to failure on cadaver specimens [45]. Additionally, in cases where an internal caryatid was utilized for reinforcement of the ATFL repair, Schuh et al. found that the torque to failure equally well as inversion bending at fourth dimension of failure was really greater for the group with the internal brace [46]. The about mutual mode of failure for primary repair of the ATFL besides equally the repair of the ATFL to bone utilizing a suture anchor occurred at the ligament to suture interface. This is consistent with other biomechanical investigations [47]. When suture anchor repair techniques were reinforced with the internal caryatid, the failure at that interface decreased significantly which could potentially advance rehabilitation protocols [46]. While short-term outcomes look promising for internal brace reinforcement of repairs, long-term studies are needed [48•].
Regardless of the technique for ligament repair, consideration of the anatomy is essential. While the ATFL is the classically repaired ligament for lateral CAI, it is important to consider CFL repair when performing lateral talocrural joint stabilization. A recent biomechanical written report plant significantly increased tibiotalar contact pressures and greater inversion of both the talus and the calcaneus with sectioning of the CFL indicative of the importance of a competent CFL for success of stabilization [eighteen••]. Despite this finding, there are multiple studies showing splendid outcomes with isolated ATFL repairs, and every bit such CFL repair can be left to surgeon discretion [41, 42•]. Park et al. reported that the presence or absence of the ATFL remnant did not negatively affect the clinical outcome of patients undergoing a modified Broström procedure as described by Gould [49••]. In this study, the ATFL was evaluated on MRI, ultrasound, and arthroscopically with absence of or differences in ATFL morphology having no pregnant effect on the Human foot and Ankle Outcome Scores (FAOS). Maffulli et al. reported a 9-yr follow-upwardly for 38 patients who underwent open up modified Brostrom surgery addressing only the ATFL with 58% continuing at pre-injury sporting level. At that place was a 16% failure rate in this group at 9 years [50].
Functional chronic talocrural joint instability is nigh oftentimes attributed to an imbalance of muscular control in addition to deficits in proprioception and oftentimes co-exists with mechanical instability [11•]. Afterward ligament repair and restoration of mechanical stability to the ankle, information technology is of import to address the functional instability factors with therapy as the patient recovers. Cho et al. establish that at intermediate follow-up (2 years) following modified open Brostrom, peroneal strength was restored to 82.6% compared to the contralateral side. Despite the importance of peroneal force in the conservative management of CAI, the outcomes of the open up Brostrom were not significantly affected by peroneal muscle recovery, and all patients reported an FAOS score of greater than ninety at ii-twelvemonth follow-up [40••]. 4.9% of the patients reported recurring instability.
Anatomic repair remains the most common treatment for chronic lateral ankle instability with the golden standard of the Brostrom-Gould technique. There are instances, yet, where direct repair is contraindicated including those patients with significant generalized ligamentous laxity, prior unsuccessful anatomic repair, or secondary reconstructions and those with high body mass alphabetize. Beighton scores greater than or equal to four have been associated with higher failure rates after anatomic repair surgery [36, 51]. In these cases, as described in other capacity in this text, anatomic ligament reconstruction or augmented repair is an excellent option for stabilization and has been establish to have similar outcomes to the Brostrom-Gould technique [52, 53••]. Information technology is important to identify hindfoot or tibia vara during physical and imaging evaluation as the cavovarus foot can independently lead to failure of the ligament repair [23].
Conclusion
The open up modified Brostrom lateral ligament repair remains the gold standard for surgical treatment of chronic lateral ankle instability. The outcomes for patients who undergo this procedure are fantabulous and accept passed the test of time. Every bit new techniques, including arthroscopic repairs, as well equally reinforcement techniques are being utilized, long-term studies are needed to truly investigate how the outcomes compare to the open procedure. These newer methods may in fact atomic number 82 to better results if reinforcement and minimally invasive techniques can lead to faster and more ambitious rehabilitation protocols.
Compliance with Ethical Standards
Conflict of Interest
Rebecca Griffith declares that she has no conflict of involvement.
Kenneth Hunt declares that he has no disharmonize of interest.
Human and Animal Rights and Informed Consent
This commodity does not contain whatever studies with human or creature subjects performed by whatsoever of the authors.
Footnotes
This article is role of the Topical Collection on Management of Ankle Instability
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Contributor Information
Kenneth J. Hunt, Email: ude.ztuhcsnauc@tnuh.j.htennek.
Rebecca Griffith, Electronic mail: ude.ztuhcsnauc@htiffirg.accebeR.
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Articles from Current Reviews in Musculoskeletal Medicine are provided hither courtesy of Humana Press
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7661567/
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