Acute ankle sprains are most frequently treated conservatively, although some surgeons may advocate acute repairs in certain situations. Surgery is indicated for chronic sprains with persistent ankle instability despite well-designed conservative management. Several anatomic and nonanatomic operative procedures are available. The Brostrom-Gould procedure is a widely-used operative intervention for treatment of chronic lateral ankle sprains. It consists of an anatomic repair or reconstruction of the injured lateral ankle ligament complex (Brostrom procedure), followed by suturing of the inferior extensor retinaculum to periosteum of the distal fibula (Gould modification).
This article describes the standard Brostrom-Gould procedure starting with the identification of the anatomic landmarks. The skin incision follows the anterior border of the distal fibula, and careful subcutaneous dissection is carried out to expose the extensor retinaculum and the torn ligaments. This is followed by bone preparation and ligament repair utilizing a box stitch technique while holding the ankle in an appropriate position. Finally, the Gould portion of the procedure is demonstrated.
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This article is the companion to the JoMI articles:
- Deltoid Ligament Repair
by Eric Bluman, MD, PhD
- Peroneal Tendon Debridement
by Eric Bluman, MD, PhD
- Five-Month Patient Follow-Up following Ankle Ligament Reconstruction
by Eric Bluman, MD, PhD
Table of Contents
- IV antibiotics administered and popliteal and saphenous nerve block placed
- Make Anatomic Landmarks
- Incision 4.0 cm Proximal to Tip of Fibula, Curving Towards Sinus Tarsi
- Incision should be 6cm long curving incision distally and posteriorly around the distal tip of the fibula
- Must be able to access ATFL and CFL from your incision
- Locate Anterior Central Branch of Superior Peroneal Nerve and Retract
- Also ID and preserve Sural Nerve Posteriorly
- Identify and Incise Extensor Retinaculum
- Incise Anterior retinaculum with Metzenbaum scissors. This will be repaired at the end of the case.
- Mobilize Soft Tissues
- Find and Define Anterior Tibiofibular Ligament (ATFL) which runs perpendicular to fibula, about 1 cm proximal to its tip
- Use a right angle snap to define its borders
- Cut ATFL Remnant and Elevate
- This will later be sewn to Calcaneofibular Ligament (CFL)
- Debride Anterior Distal Fibula
- Retract Peroneal Tendons Inferiorly to Expose CFL
- Incise the peroneal sheath to identify the peroneal tendons and retract them posterioriy.
- CFL is located on the floor of the peroneal sheath, heading posterolaterally off tip of the fibula.
- Sew ATFL remnant to CFL with #1 Ethibond Sutures
- Use Box Stitch technique
- Foot should be in Dorsiflexion and Eversion
- Oversew Repair with #0 Vicryl Sutures
- Keep Foot in Dorsiflexion and Eversion
- Two Layer Closure
- Dress Wound and Apply Posterior Splint
So what we getting ready to do right now is a classic lateral ankle ligament repair namely the Brostrom-Gould Procedure and I'm going to use a fairly standard incision that allows good exposure of the joint line and allows good identification and mobilization of the tissues that we're going to need to reef up and repair. So I’ve got my fibula depicted here with the hash marks we've already done a peroneal tendoscopy here and that's what these sutures are. We're going to go ahead and fix the lateral ankle ligament complex here. So, essentially I'm going to initially find where the lateral shoulder of the talus is and it's right about here, we're not going to need to go up any farther than that. I'm feeling the distal fibula here and tip of the fibula is really down here so going right down along here is going to provide us with good access to the lateral ankle ligaments. One of the questions that is commonly brought up is that this could be at near right angles to incisions if you need to come down and do a tendon repair or do a fibular fracture in the future. I haven't come across any problems with tissue necrosis or poor healing in these cases and I think this is a safe combination to make especially if they're separated temporally from each other. So we'll go ahead and start this portion of the case.
So we’ll make this incision here, go through here, watch out and make sure that we're identifying and protecting branches of the superficial peroneal nerve. I'm going to do a little bit of dissection here. Using a jake right here just to mobilize some of these vessels. Try to preserve as many of these draining vessels as possible, but in this case it's we’re going to have to take these vessels. I haven't had any problems with significant swelling postoperatively secondary to decrease vascular outflow. That might be a little branch there, huh? This looks like a little superficial branch of the superficial peroneal nerve so we're going to leave that alone and I'm going to skeletonize it just a little bit to make it a little more mobile, so we can move it out of the way, but I think we're going to be able to retract it out of the way. Go ahead and give me a ragnell please.Yeah. I think we're pretty good otherwise - looking good. I don’t know if that’s anything there, that's not really a position for anything, we can take that out of the way. Ya, maybe it’s a little branch - could be. Give me a knife, please.
[second surgeon]: Yeah, we're done with the tower. Thank you.
Now I’m just going to go back to the knife and I'm going to open up the - there's a little bit of fatty tissue here. I think this is it here and I'm just going to raise up, raise up some of that. You can see here, this is a layer that's developing and that's going to be I think helpful for us. Down here we're going to be close, very very close, to the peroneal tendons and we want to make sure that we're not damaging those. So again this is this is the retinacular fibers here, I'm going to switch hands here and just develop this underneath. You can see here's capsule underneath us and this is some extensor retinaculum right here as well and I'm going to develop this plane because it's going to be a nice little pants over vest I think later on. So now I’ll go up right underneath this and in this patient is a pretty stout layer which is good, it's going to help us. You know she's pretty much plantarflexed and inverted which is not where she's going to end up and I think we're going to be able to mobilize that very very well later on. So here's a little bit extra tissue that were going to be able to use and incorporate that. What I’ve done here is I'm just bluntly coming up on the distal fibula which is right here, and what I'm doing now is I'm actually feeling to say, okay, where am I going to make my incision here in this very much attenuated portion of the capsule. There no rents in it but you can see it's pretty beat up and scarred in. This is a lot of scar tissue here attached, and that's peroneals right in here, you can see them and that's about as distal as we're going to have to go even if we have to go into the to the CFL. So I'm feeling here for the joint line. Okay, let me have a knife please, and I'm going to go right in here. Right off the distal fibula, and I'm going to lift this tissue. This is the ATFL right here and it's moving down into the CFL.
[other surgeon]: More posterior, right?
Yeah, more inferior and posterior. This is just scar tissue here that I'm going to release from the distal fibula and it’s going to allow me to eventually look into the joint. Okay. Okay, so again this is now the extensor retinaculum here we're going to use for Gould modification and I'm lifting up the tendon - rather excuse me - the ATFL off of the fibula and I'm also going to create a little bare spot on the fibula for this tissue to heal down onto. You can see some of that fluid coming out from the joint. Can I have a freer, please? We’re just releasing some of the scar tissue underneath so that she has - we got some excursion we can actually reef it up to a place where she's stable. I'm clearing off tissue from the distal fibula to leave a nice footprint for this to heal back down.
I’m developing that plane between the talus now. You can see the talus here and we really need to free up all the tissue in there. Knife please. There's the fibular cartilage right there. That really released it and that's good because now we can hike that up. Let’s take a quick look at the CFL. Actually surprising the CFL looks fairly intact here. ATFL is clearly out.
Alright so now we've got, we're able to do our repair and we're going to ask for some number one ethibond sutures if we have it. So this is our, again this is our capsule here, and then this is the extensor retinaculum right here that we're going to use to reef over and probably attach it to this tissue at the end. So we're going to take our ligamentous tissue and do a repair right now. We’re going to put probably 3 sutures in there. Okay.
So this is some pretty heavy gauge, non-absorbable suture we're going to use for this and what I'm going to do is create a stitch that we're going to be able to use. Take this out of the way please. This is our cuff from before. I'm there I think we're going to be able to put three good sutures in this location. I'm going to put the a stitch in through here - do we have anything on a smaller needle? You have a 1?
[other surgeon]: That is a number one.
This is the smallest needle we got? Okay. So I’m going to put what we call a little box stitch here. I'm going to come up through here in this tissue, we're really going to take a pretty healthy bite to reef it up. You can create a little box stitch which I'm going to hopefully illustrate for you guys right here. You usually start out with something akin to a horizontal mattress suture. Then you’re going to come back underneath the tissue cuff and that suture is going to be a reinforcement for another stitch that you’re going to take right here. It’s more of a cross stitch but we call it a box stitch. And then this is going to come back up through that tissue sleeve that we created before. One more, you’re right. And again we’re just going to do a repeat of what we what we just did. Box stitch coming through the proximal sleeve, so again we got this cross stitch right here, I don't know if you guys can see it in close up. It’s a little cross stitch - box stitch. And again we’re going to finish up with a little, going proximal, grabbing a nice tissue bite.
[other surgeon]: One more?
So now, I think we're going to be alright. We’re going to have nice coaptation of that tissue, I think.
[other surgeon]: Ya it’s perfect.
Okay so we tie from inferior first so what I'm going to do is we're going to tie it off here and put a little clamp on it just to hold it in place. We're not going to snap it down on the suture we're just going to hold it in place on the tissues just like this. You'll see what I'm talking about here so - no not yet, not yet. Hold that up please - yep. That's going to lock that suture down for me. Cut that off. And then the other one we're going to do the same thing. Greg, with the other hand please hold this here, ya, and move this up here - a little bit deeper, okay. You can see that’s going to reef that up very nicely. Now we’re going to keep the good position of the foot dorsiflexion and eversion, and now I'm going to take the vicryl suture and oversew this repair that I just did with figure-of-eight sutures.
[other surgeon]: Have any preference for interrupted versus running?
Ya I think that these are definitely strength sutures, I think they all need to be interrupted. That completes that the Brostrom portion and now what we need to do is - you can see that that that holds pretty nicely - but we're going to do is take this retinaculum that we developed earlier and actually sew it.
Look at this. Take that down, we’ll reef those two together pretty tightly. I think this is going to be a nice augmentation to our to Brostrom. So here we go again. Here's the retinaculum. And I do this with with absorbable, this is pretty superficial underneath the skin. Certainly in thin people and ladies, you know it can be very prominent, the knots can be prominent if you're using non-absorbables and especially large gauge sutures. So you can see that look at that nice coming together reefed.