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Stabilizing The Lateral Ankle Via A Brostrom Repair With Suture Tape Augmentation
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ting a case involving the use of suture tape augmentation with a Brostrom repair for the treatment of ankle instability, this author says the technique increases the strength of the repair and allows for faster recovery and an earlier return to sports.
Ankle sprains are among the most common injuries in sports. The majority of sprains (85 percent) involve the lateral ankle and up to 25 percent of patients fail to respond to non-operative care, and continue to experience symptoms of functional or mechanical instability.1 Continued pain and instability, despite extensive non-operative strategies, often interfere with the patient’s ability to return to previous sports. Surgical intervention is often indicated with the goal of returning patients to their previous level of activity.
The Brostrom procedure is a proven surgical technique for the repair of the lateral ankle ligamentous structures. The procedure, originally described in 1966, is based on a direct anatomic repair of the anterior talofibular ligament.2,3 Clinical outcome studies report 90 to 95 percent good to excellent long-term results.4 Each of the series reporting these results recommend four to six weeks of immobilization in a short leg walking cast.5
Although the Brostrom repair has proven to be successful at restoring stability and function, the direct repair at the time of surgery is significantly weaker than that of the intact anterior talofibular ligament.5 Waldrop and colleagues performed a cadaveric biomechanical comparison of the ultimate load to failure and stiffness of the traditional Brostrom technique (pants over vest suture repair) to a suture anchor repair of the anterior talofibular ligament (with suture anchors placed in the fibula or talus). Testing revealed that all three fixation methods were equal with respect to ultimate failure and stiffness. However, all three were significantly weaker than the native intact anterior talofibular ligament. The immediate strength at the time of surgery was less than half. These results highlight the need for early protection of all three types of repairs and the authors caution early rehabilitation to prevent elongation of the repair and recurrence of instability.5
Karlsson and coworkers demonstrated that early mobilization after anatomic lateral ankle ligament reconstruction allows for earlier return to sport and greater plantarflexion strength in comparison to patients who have been immobilized.6,7 Most surgeons advocate protected range of motion after repair of the lateral ligament complex to prevent postoperative ankle stiffness, muscle atrophy and weakness.8 However, elongation of ligaments during early mobilization after reconstruction may be associated with increased laxity and decreased stability.8
Authors have described numerous modifications of the original Brostrom technique to reinforce the repair, including the use of inferior extensor retinaculum or tendon augmentation.9,10 The retinacular tissue, though, is often thinner and more fragile than the lateral ligamentous structures themselves. Behrens and colleagues showed that the extensor retinaculum used in the Gould modification provided little additional stability.11 Autogenous tendon augmentation sacrifices a normal functioning tendon.
Recently, Veins and coworkers showed increased strength and stiffness in incorporating suture tape augmentation with the standard Brostrom repair.12 This technique may be valuable in allowing patients earlier rehabilitation.
A Closer Look At The Patient Presentation And Surgery
The following case illustrates the use of suture tape augmentation with a standard Brostrom repair in an athletic patient with chronic ankle instability. This was a high-school athlete who sustained a severe, grade 3 lateral ankle sprain. Despite extensive conservative treatment, he was unable to return to sports due to continued pain and instability. After careful consideration, he and his family elected for surgical intervention.
I used a standard incision and dissection for a Brostrom repair. I identified the capsuloligamentous ends, distal fibula and talus. I placed the talar tunnel at the anterior talofibular ligament attachment (an area of non-articulating surface) and 45 degrees posteromedially into the body of the talus. I inserted an anchor loaded with suture tape into the talar tunnel and passed both ends of the suture tape through the capsuloligamentous tissue. I proceeded to make a drill hole in the distal fibula, angling it slightly proximal. Using a K-wire in the drill hole assisted in locating the tunnel after the Brostrom repair. The foot was in relaxed plantrflexion and slight eversion with a bump under the tibia to prevent anterior translation of the talus. I placed non-absorbable sutures through the sectioned capsuloligamentous ends for repair in a pants-over-vest technique. After performing the Brostrom repair, I passed both limbs of the suture tape through the eyelet of the anchor and seated the anchor into the previously drilled fibula tunnel superficial to the repair. I verified the stability with the anterior drawer test.
I closed the surgical wound in a layered fashion and the patient wore a well-padded compressive dressing with a posterior splint. The patient went home with crutches and instructions to remain non-weightbearing. At two weeks, I removed the sutures and placed him in a tall controlled ankle motion (CAM) boot. The patient started a home exercise program and I arranged for physical therapy. Over the course of two weeks, he gradually transitioned to full protected weightbearing in the boot. After four weeks, the patient presented to the office wearing an off-the-shelf ankle brace and sneakers. At six weeks, he was able to swim and ride a bicycle without discomfort. At eight weeks, the patient returned to full activities including running and jumping, and his ankle remained stable.
In Conclusion
This technique is not meant to act as an “artificial ligament” but more of a checkrein to protect the underlying Brostrom repair from elongating during the healing phase. Whether one uses all suture or an anchor technique, the actual Brostrom repair remains the most important aspect of the procedure. The suture tape augmentation only serves to protect the underlying repair during the healing phase by increasing the strength of the overall repair at the time of surgery. This allows earlier rehabilitation and a potentially earlier return to sports. Initial results are promising but like all new techniques and technology, long-term studies are necessary to prove this technique results in improved patient outcomes.
Dr. Bevilacqua is a board certified, fellowship trained foot and ankle surgeon with North Jersey Orthopaedic Specialists in Teaneck, NJ. He is a Fellow of the American College of Foot and Ankle Surgeons.
References
1. Gerber JP, Williams GN, Scoville GR, et al. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int, 1998; 19(10):653-60.
2. Brostrom L. Sprained ankles. V. Treatment and prognosis in recent ligament ruptures. Acta Chir Scand. 1966; 132(5):537-50.
3. Brostrom L. Sprained ankles. VI. Surgical treatment of "chronic" ligament ruptures. Acta Chir Scand. 1966. 132(5):551-65.
4. Bell SJ, Mologne TS, Sitler DF, Cox JS. Twenty-six-year results after Brostrom procedure for chronic lateral ankle instability. Am J Sports Med. 2006; 34(6):975-8.
5. Waldrop NE 3rd, Wijdicks CA, Jansson KS, et al. Anatomic suture anchor versus the Brostrom technique for anterior talofibular ligament repair: a biomechanical comparison. Am J Sports Med. 2012; 40(11):2590-6.
6. Karlsson J, Rudholm O, Bergsten T, et al. Early range of motion training after ligament reconstruction of the ankle joint. Knee Surg Sports Traumatol Arthrosc. 1995; 3(3):173-7.
7. Karlsson J, Lundin O, Lind K, Styf J. Early mobilization versus immobilization after ankle ligament stabilization. Scand J Med Sci Sports. 1999; 9(5):299-303.
8. Kirk KL, Campbell JT, Guyton GP, et al. ATFL elongation after Brostrom procedure: a biomechanical investigation. Foot Ankle Int. 2008; 29(11):1126-30.
9. Gould N, Seligson D, Gassman J. Early and late repair of lateral ligament of the ankle. Foot Ankle. 1980; 1(2):84-9.
10. Girard P, Anderson RB, Davis WH, et al. Clinical evaluation of the modified Brostrom-Evans procedure to restore ankle stability. Foot Ankle Int. 1999; 20(4):246-52.
11. Behrens SB, Drakos M, Lee BJ, et al. Biomechanical analysis of Brostrom versus Brostrom-Gould lateral ankle instability repairs. Foot Ankle Int. 2013; 34(4):587-92.
12. Viens NA, Wijdicks CA, Campbell KJ, et al. Anterior talofibular ligament ruptures, part 1: biomechanical comparison of augmented Brostrom repair techniques with the intact anterior talofibular ligament. Am J Sports Med. 2014; 42(2):405-11.
