The modified Broström procedure, also termed the Broström-Gould procedure, is the method of choice for most patients with lateral ankle instability. The patient is taken to the operating room and examined under anesthesia. If the surgeon has any questions about the degree of ankle instability, stress x-ray films (stressing the ankle in both inversion and anterior drawer) are taken. The thigh is then secured on a well-padded thigh holder in preparation for ankle arthroscopy, as described in Chapter 30. The lower extremity is prepared and draped in standard fashion. Arthroscopy is performed first; the authors of this chapter have found that 93% of patients have additional intraarticular ankle pathology associated with lateral ankle instability in one study.⁵ More recently, in another study, we found 95% of patients had associated intraarticular problems noted at arthroscopy before the Broström procedure.²⁵ In addition, a similar report by Taga showed 95% of patients have additional intraarticular pathology at the time of ankle reconstruction.²⁶ Hua and associates²⁷ found 91% of patients to have intraarticular lesions at the time of the modified Broström reconstruction.

The intraarticular pathology is identified and addressed through arthroscopic surgery. The scarred anterior talofibular (ATF) ligament is identified and assessed to make sure it is adequate for the modified Broström repair. After the arthroscopy is completed, the nurse removes the thigh support and places the leg flat on the surgical table. The ankle is reswabbed with a sterile antibacterial solution. An additional clean surgical drape is placed over the foot and ankle, and gloves are changed. New sterile instruments are used to perform the open portion of the procedure. Arthroscopic methods are now available for surgical reconstruction of the lateral ankle ligaments, but at this time open stabilization as described by Broström gives a better, more reproducible result. Recently, Corte-Real and Moreira,¹¹ Lui,²⁸ Nery and associates²⁹ reported on their arthroscopic method for chronic lateral ankle instability. The results had a high percentage of good-excellent results, but long-term studies are necessary to compare the arthroscopic with the open procedures before a recommendation can be made for switching to all-arthroscopic techniques.

After arthroscopy the ankle is prepared and the tourniquet inflated. An incision is made over the lateral aspect of the ankle. This incision may be obliquely shaped in the skin folds or more vertical from the fibula toward the sinus tarsi, depending on the surgeon’s preference and the clinical situation. The senior author prefers the vertical incision because it allows better assessment of the peroneal tendons and can be extended distally and proximally if other procedures need to be done. Dissection is carried down through the subcutaneous tissues and the extensor retinaculum is carefully exposed because it is to be used for later reattachment. The surgeon must take care to avoid the intermediate dorsal cutaneous nerve, the lateral branch of the superficial peroneal nerve (which often lies near the end of the ATF ligament), and the sural nerve (which lies over the peroneal tendons). An oblique capsular incision is then made along the anterior border of the fibula from the AITF ligament to the CF ligament, leaving a small 3- or 4-mm cuff of tissue on the fibula for reattachment of the torn ligament complex (Fig. 28-2). The stretched ATF ligament is found as a thickening in the anterior capsule, and the CF ligament is found in the distal portion of the wound under the tip of the fibula, running deep to the peroneal tendons. The CF ligament often is attenuated or avulsed from the fibular tip.

A “pants-over-vest” overlapping suture technique is used to imprecate or shorten the torn ligaments and provide a double layer of reinforcement to the repair. Suturing is done starting from the ligament portion attached to the talus, so that the knots are tied distal and inferior to the fibula (Fig. 28-3). This helps prevent postoperative knot prominence and skin irritation with shoe wear. “O” nonabsorbable sutures are used in the majority of the repair, but one absorbable suture is used for the CF ligament near the peroneal tendon, to avoid irritation. The sutures are tied with the ankle in neutral position, and a posterior drawer is applied to reduce the talus. The ankle is checked to make sure full ROM has been maintained during the repair. The extensor retinaculum is then pulled proximal over the repair and sutured to the fibular periosteum. ROM is again checked, as is the stability of the ankle. The tourniquet is released, and bleeding tissues are coagulated. The subcutaneous tissue and skin are then closed in the standard fashion. The patient is placed in a short-leg well-padded cast that is split in the recovery room to allow for swelling.

The patient’s cast is changed at 1 and 2 weeks and the stitches are removed. Weight bearing is started at week 3 in a cast or cast boot, at the surgeon’s discretion. Physical therapy with mobilization starts usually at week 6 or sometimes sooner.

Indications for an anatomic hamstring reconstruction include a high-stress, heavy athlete, generalized ligamentous laxity, deficient ATF ligament tissue for direct repair, talar tilt greater than 10^o more than the opposite ankle, and a varus hindfoot. The incision used is the same as shown in Fig. 28-2, A. The lateral ligaments are released in the same oblique fashion for later reattachment over the hamstring repair. An autogenous or allograft semitendinosus graft is prepared with nonabsorbable sutures at both ends. A guidepin is inserted into the fibula to create two converging bony tunnels, beginning from insertion of the ATF ligament on the fibula, as well as the insertion of the CF ligament on the fibula. These tunnels are connected using a curved curette. Alternatively, as option B, the holes can be drilled out the posterior fibula to increase the bone bridge between the anterior talofibular ligament (ATFL) arm and the calcaneofibular ligament (CFL) arm. A reamer is then placed over the guidepin to create 5-mm tunnels. A guidepin is then inserted along the talar neck at the nonarticular portion and reamed to a predetermined size based on the diameter of the graft (Figs. 28-4 and 28-5). A passing device is placed from posterior to anterior through the fibula to facilitate graft passage (Fig. 28-6). The graft is then fixated on the talus with a special interference screw that helps push the tendon into the bone socket (Fig. 28-7). Alternatively, in option B, the graft can be passed from anterior to posterior and the ATF arm can be separately tensioned and fixed with an interference screw before tensioning the CFL arm (Fig. 28-8). This is usually done in slight plantar flexion because this is when the ATF ligament is the tightest. The tensioning on the CFL arm is done in slight dorsiflexion, and the tendon is passed underneath the peroneal tendons to exit into a drill hole made through the calcaneus. The CFL arm is cut so that 20 mm of the tendon will be in the calcaneus when it is secured with an interference screw (Fig. 28-9). This is done with the ankle in neutral position by bringing the sutures out through a poke hole on the medial heel and pulling tension on the sutures while the screw is inserted in the calcaneus (while pulling the graft into the tunnel) (Fig. 28-10). The final constructs gives anatomic reconstruction of the ATFL and CFL (Fig. 28-11). A modified Broström repair is then done over the hamstring reconstruction.

The patient is then placed in a cast which is split in the recovery room. The cast is changed at 1 and 2 weeks, and the stitches removed. Weight bearing is started at week 3 in a cast or a cast-boot at the surgeon’s discretion. Physical therapy usually starts in the pool at week 6 or 8, depending on what else is done at surgery.

The physical therapist has a responsibility to the surgeon and the patient to protect the lateral ligamentous reconstruction. Forefoot inversion stresses the reconstructed tissues and must be carefully engaged. Manual muscle testing to determine strength of the lower extremity can be part of the initial evaluation. However, muscle testing at the ankle is delayed until the patient has progressed and accommodated to resisted exercises at the ankle. The therapist should avoid having the patient perform a single–leg heel raise, which is usually advocated to determine normal gastrocnemius-soleus strength, because of decreased proprioception and the significant muscle deficits resulting from the effects of immobilization. The incision is assessed for mobility and hypersensitivity after complete healing has occurred. Operative damage to the sural nerve and the lateral branch of the superficial peroneal nerve has been reported as a cause of decreased sensation in the involved ankle.10,37 Joint effusion and soft tissue edema can be factors in limited ROM, proprioception deficits, and the inability to strengthen the joint. Joint and soft tissue mobility also are assessed at the limits of ROM.

GOALS: Decrease pain and swelling, restore joint and soft tissue mobility, increase strength in lower extremity and ankle, increase proprioception, normalize gait, maintain cardiovascular fitness, and provide patient education (Table 28-1)