Brostrom-Gould Procedure for Lateral Ankle Instability

CHAPTER 1

So, what we're getting ready to doright now is a classic lateral ankleligament repair, namely the Brostrom-Gould Procedure.I'm going to usea fairly standard incision that allowsgood exposure of the joint lineand allows good identification andmobilization of the tissues thatwe're going to need to reef up and repair.So I’ve got my fibula depicted herewith the hash marks we've already done aperoneal tendoscopy here,and that's what these sutures are. We're going to goahead and fix the lateral ankle ligament complex here. So,essentially, I'm going to initially findwhere the lateral shoulder of the talus is andit's right about here,we're not going to need to go up any fartherthan that.I'm feeling the distal fibula here, and tip of the fibula isreally down here so going right down along here is going toprovide us with good access to the lateral ankle ligaments.One of the questions that is commonly brought upis that this could be at nearright angles to incisions if you need to come down and do atendon repair or do a fibular fracture in the future.And - I haven't come across any problems with tissuenecrosis or poor healing in thesecases and I think this is a safe combinationto make, especiallyif they're separated temporally from each other.So we'll go ahead and startthis portion of the case.

CHAPTER 2

So we’ll make this incision here, go through here,watch out and make sure that we're identifyingand protecting branches of the superficial peroneal nerve.I'm going to do a littlebit of dissection here,using a Jake right here just to mobilize someof these vessels.Try to preserve as many of thesedraining vessels as possible,but in this case it's we’re going to have to take these vessels.I haven't had any problemswith significant swelling postoperativelysecondary to decreased vascular outflow.That might be a little branch there, huh?This looks like a little superficial branchof the superficial peronealnerve so we're going to leave that alone and I'mgoing 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 goingto be able to retract it out of the way.

Go ahead and giveme a Ragnell, please.I think we're pretty good, otherwise. It's looking good.Yeah, maybe it’s a little branch - could be.Give me a knife, please.

CHAPTER 3

Now I’m just going to go back to the knifeand I'm going to open up the - there's a little bit of fatty tissue here.And I think this is it here, and I'm just going to -just gonna 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 tobe close, very very close, to the peroneal tendons.And we want to make sure that we're not damaging those.This is this is the retinacular fibers here,I'm going to switchhands here and just develop this underneath.You can see here's capsule underneath us,and this is some extensor retinaculum right here aswell, and I'm going to develop this planebecause it's going to be aa nice little pants-over-vest, I think, later on.So now I’ll go up rightunderneath this.And in this patient, it's a pretty stout layer, which is good.It's going to help us.You know, she's pretty much plantar-flexedand inverted, which is notwhere she's going to end upand I think we're going to be ableto mobilize that very very well later on. So here's a littlebit extra tissue that we're going to be ableto incorporate that, and I'm just bluntly coming up on thedistal 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 thisvery much attenuated portion of the capsule.There no rents in it but you can see it's pretty beatup and scarred in.This is a lot of scar tissue here attached,and that's peroneals, right inhere, you can see themand that's about as distal as we're going to have to go even ifwe have to go into the to the CFL.I'm feeling here for the joint line.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, andit's moving down into the CFL.More posterior, right?Yeah, more inferior and posterior.This is just scar tissue here that I'mgoing to release from the distal fibulaand it’s going to allow me to eventually look into the joint.You want to readjust?Okay, so again this is now the extensorretinaculum here.

What we're going to use forour Gould modification, and I'm lifting upthe tendon - rather, excuse me - the ATFLoff of the fibula, and I'm also going to create...A little...Bare spot on the fibula forthis 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 underneathso that she has -we got some excursion, and we can actually reef it upto a place where she's stable.Again, I'm clearing off tissue from the distal fibula to leave a nicefootprint for this to heal back down to.

CHAPTER 4

I’m developing that plane betweenthe talus now.You can see the talus in here.And we really need to free up all the tissue in there.Knife, please.And there's the fibular cartilage, right there.That really released it and that's good becausenow we can hike that up.

Let’s take a quick look at the CFL. Actually surprising theCFL looks fairly intact here.ATFL is clearly out.

CHAPTER 5

Alright so now we've got -we're able to do our repair, and we're going to ask for some#1 Ethibond sutures if we have it.And so this is our, again this is our capsule here.And then this is the extensor retinaculum right herethat 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 tissueand 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 usefor this.And what I'm going to do is create a stitch that we're going tobe able to use. Take this out of the way, please. This is ourcuff from before...I think we're going to be able toput three good sutures in this location.I'm going to put a stitch in through here.Do we have anythingon a smaller needle?You have a 1?That is a #1. This is the smallest needle we got?Yep. Okay.So I’m going to put what we call a little box stitch here.I'm going to come up through herein this tissue, and we're really going to take a pretty healthy biteto reef it up.And create a little box stitch, which I'm going tohopefully illustrate for you guys, right here.You usually start out with something akinto a horizontal mattress suture.Then you’re going to come back underneath the tissue cuff.And that suture is going to be a reinforcementfor another stitch.You're going to take right here.It’s more of a cross stitch, butwe call it a box stitch.And then this is going to come back upthrough that tissue sleevethat we created before.One more, you’re right.And again we’re just going to do a repeatof 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 guyscan see it in close up.It’s a little cross stitch - box stitch.And again we’re going to finish upwith a littlegoing proximal,grabbing a nice tissue bite.So now - I think we're going to be alright.We’re going to have nice coaptation of that tissue, I think.Yeah it's perfect.Do you have a snap? Or snaps?Okay so we tie from inferior first.So what I'm going to do is -we're gonna tie it off here, and put a little, yeah, a little clamp on itjust to hold it in place. We're not going to snap it down onthe suture we're just going to hold it in placeon 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.Yeah, and move this up here.A little bit more. A little bit deeper, okay.You can seethat’s going to reef that up very nicely.

Now, we’re going to keep the good positionof the foot dorsiflexion and eversion,and now I'm going to take the Vicryl sutureand oversew this repair that I just did -figure-of-eight sutures.Have any preference for interrupted versus running?Yeah, I think that this isa strength - 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 dois take this retinaculum that we developed earlierand actually sew it. Look at this.Take that down, we’ll reef thosetwo together pretty tightly.And 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 absorbable.This is pretty superficial underneath the skin.Certainly in thin people,ladies, you know it can be very prominent -the knots can be prominent ifyou're using non-absorbables,especially large gaugesutures.So you can see that - look at that nice, coming together - reefed.Again, I'm taking pretty generous bites here becauseI'm going to use this to strengthen and reinforce the repair.Bringing the tissues together is going to tighten this up.When would you consider doing bone tunnels?Good question - I do bone tunnelswhen I'm doing a combined open peroneal procedure and Brostrom.And I do all the bone tunnels straightthrough the fibula and tie it right on the backsideI also repair - you're reefing your ATFLand your lateral ligament complex with the same sutures that you're using to close your superior peroneal retinaculum.The other thing that people do is -suture anchors - I think it's fine.I sometimes do that.If I can't mobilize the tissue on the top or I'mworried that I'm not going to have a very stable repair,I'll do that.And again, this is looking pretty good.You're seeing the superior peroneal retinaculum.The tissues have been reefed closed.They're nice and stable.

I'm gonna give it a little test nowon the lateral side to seeif her - and she's nice and stable now.I don't see any sulcus sign.I don't see any big movement there.That's a very stable repair.

CHAPTER 6

Now, what we'll do is I'll keep this... Some irrigation, please.I'll keep this dorsiflexion and eversion soI don't stress the repair during the closure.I do a two layer closure - subcutaneous layer and skin.And then we're going to go dorsiflexion, everted splintto hold her in a good position while this heals.