Brostrom Procedure: How Surgeons Tighten Loose Ankle Ligaments

Introduction

Brostrom or the modified Brostrom, also known as the Brostrom-Gould procedure, is a well-researched and popularly performed operation to treat chronically unstable ankles, which is most likely due to torn anterior talofibular or the calcaneofibular ligament, resulting in chronic instability.

It may well be that the ligaments are stretched out and therefore not providing suitable support, and are insufficient rather than torn.

What Causes Loose Ankle Ligaments?

Loose ankle ligaments are usually caused by acute or chronic trauma.

It could be that there have been one or more injuries where the patient has suffered from an ankle sprain or it may be related to the fact that the patient has hypermobility disorders, for example, Ehlers-Danlos or just a high hypermobility index which results in stretchy ligaments and therefore they don’t have the protection from the ligaments and support resulting in chronic instability of the ankles. Occasionally, we also see that certain foot types, such as a cavus high arch foot type, can result in a higher incidence of unstable ankles.

What is the Brostrom Procedure?

The Brostrom procedure is an operation performed under general anaesthetic or deep sedation and is to repair and stabilise the lateral ankle ligaments. There are a few variations; sometimes an internal brace from Arthrex is used, or standard pants over vest tightening of the ligaments and joint capsule is performed.

Step-by-Step: How the Procedure Works

• An incision is made over the anterior lateral ankle. This is either a curved incision or a long linear incision over the outer bone of the ankle, known as the fibula.
• The nerves and important soft tissue structures are protected.
• The joint capsule is identified, and an incision along the border of the distal fibula is made.
• The ankle joint is exposed; the torn ligament ends are identified.
• Usually, fibre wire is used to perform a pants over vest tightening and repair and augmentation of the ligaments; both the ATF and the CF ligament, if damaged, are repaired.
• Sometimes bone anchors are used in the fibula to augment the repair.
• If the ankle remains unstable, then an Arthrex internal brace is used by me, which augments and sits as an artificial ligament on top of the area.
• The skin is then closed.
• The reinforcement procedure is known as a Brostrom-Gould modification, where the extensor retinaculum is stretched and repaired over the main repair.
• Closure is performed using a non-absorbable or absorbable stitch at the surgeon’s preference and patient needs. A below-knee cast is applied for two weeks, and the patient is immobilised in the cast for two weeks with non-weight bearing, followed by transition into an air cast boot at two weeks following removal of sutures. And the patient is then allowed to bear weight.
• The patient will also start physiotherapy at week two following the cast removal and will be transitioned out of the boot at approximately four weeks into trainers. Gentle impact activities are allowed at six to eight weeks, but significant sports may not be allowed for three to four months post-surgery.

Key Variations of the Brostrom Procedure

The original Brostrom: This is the original Brostrom, where only the ligaments are repaired, or the capsule is tightened. There is no additional procedure performed.

The modified Brostrom-Gould technique: This technique involves repair of the tissues known as the extensor retinaculum, which protects and supports the tendons at the front of the ankle, which is an advancement over the original repair to provide a secondary strength to the repair.

The internal brace technique: This is a further modification, and I commonly use this with athletes; it allows early rehabilitation. The Arthrex internal brace provides a fibre tape repair on top, which reduces the risk of failure of the original procedure.

Arthroscopic Brostrom: This is performed in some cases through a keyhole technique. It involves less incision and soft tissue destruction. However, not all cases are suitable for this.

After Surgery: What to Expect

The benefits of the procedure are that you get a stable ankle, you can return to all activities, and you’re less likely to get a further sprain.

Risk and Considerations

The main risk can be local nerve injury, over-tightness, or prolonged swelling.

It may take a while for the swelling to calm down.

Conclusion

The Brostrom or any of its modifications are very successful at treating ankle instability. It usually has a very predictable recovery, and it’s used to treat chronic ankle instability.

Frequently Asked Questions

Q. What is chronic ankle instability?

A. Chronic ankle instability is a condition where, even on the slightest uneven surface or during sports, your ankle is prone to twisting and getting sprained regularly. The underlying cause is possibly an old injury or tear of the ligaments, which has resulted from any injury or stretching of the ligaments.

Q. What are the benefits of the procedure?

A. The benefits include stability and resolution of pain and return to sports.

Q. What is the arthroscopic Brostrom procedure?

A. This is a keyhole modification where a small camera and instruments are used to repair the ligament without opening up via a larger incision or opening the joint via a larger incision.

Q. What type of surgery is for ligaments in the ankle?

A. To repair the outer ligaments of the ankle, it is known as the Brostrom procedure. Sometimes you can also injure the medial ligaments, which need repairing.

Q. What ligament is repaired during the Brostrom procedure?

A. The main ligament repaired is the ATF ligament, known as anterior talofibular ligament or the CF ligament, the calcaneofibular ligament.