Arthroscopic modified Brostrom operation allows faster recovery in chronic ankle instability

Written By : Dr Supreeth D R |Medically Reviewed By : Dr. Kamal Kant Kohli Published On 2022-12-12T20:00:51+05:30 | Updated On 13 Dec 2022 1:01 PM IST

The modified Brostrom operation (MBO) has found widespread use in the therapy of lateral chronic ankle instability (CAI). However, alternative surgical techniques like the open reconstruction using a periosteal flap (RPF) are still an important part of the surgical treatment of lateral CAI. Both procedures differ in terms of the reconstruction material used and the surgical procedure.

Moritz Mederake et al conducted a study to compare the arthroscopic MBO and the RPF. The article has been published in – "Archives of Orthopaedic and Trauma Surgery" journal.

The authors retrospectively analysed 25 patients with lateral CAI after a tear of the anterior talofibular ligament (ATFL). 14 patients received arthroscopic MBO and 11 patients received RPF. They compared the postoperative outcome between both groups with respect to subjective instability, the number of ankle sprains, pain, complications and follow-up operations as well as the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score.

Surgical techniques:

Arthroscopic MBO:

It was performed using the Arthrex Broström Repair implant system (Arthrex Inc. Naples, Florida, USA). Viewing from the anteromedial aspect of the joint a debridement is performed with special attention paid to the preparation of the anterior aspect of the distal fibula with the anatomical origin of the ATFL. Through the anterolateral portal onto the inferior aspect of the fibula a SutureTak drill guide and drill bit are used to create two bone tunnels 5 mm and 10 mm proximal to the tip of the distal fibula. These two drill holes are armed with a 3 mm Biocomposite SutureTak anchor. 15 mm ventrodistally from the tip of the fibula 4 exit points for the suture are marked. Using a Micro SutureLasso, all four sutures are shuttled through the marked points. In the next step, all four sutures are passed subcutaneously through the anterolateral arthroscopic portal. While holding the foot in slight eversion, the sutures are fastened down to the fibula thus sewing the inferior extensor retinaculum to the periosteum of the lateral malleolus.

RPF:

The skin incision is located anterior to the distal fibula curving in the posterior direction distally at the lateral malleolus. Then two periosteal flaps from the fibula are prepared and elevated from proximal to distal. The next step is to make two drillholes at the tip of the fibula in the direction of the attachments of the ATFL and the CFL. The two periosteal flaps are now pulled through the drill holes. The insertion sites of the ATFL and the CFL have to be exposed and a cortical bone block of 10 × 10 mm is then removed. The dorsal flap is fixed in slight equinus of the foot. It is directed deep to the peroneal tendons and held under tension. The fixation with the cortical block at the prepared site of insertion of the CFL is made by a staple. Fixation of the anterior flap is made in the same way at the prepared site of insertion of the ATFL, but in a neutral position with the hindfoot in valgus at the subtalar joint.

Key findings of the study were:

• Both surgical procedures resulted in a significant improvement in pain, in subjective instability, in the reduction in the frequency of ankle sprains and improvement in the AOFAS ankle-hindfoot score one year postoperatively.

• Three months postoperatively, the values for pain and instability of the MBO group were significantly better compared to the RPF. One year after the operation, these differences were evened out.

• Also in terms of complications and follow-up operations, no significant difference was found between the two procedures.

The authors concluded that – "The MBO and the RPF are surgical techniques that yield a comparable clinical outcome one year postoperatively. Pain, function, instability and the frequency of ankle sprains improve significantly with both procedures and do not differ significantly from one another. The arthroscopic MBO appears to have the advantage of faster recovery through significantly faster pain reduction and improvement of instability. From our point of view, RPF can be seen as a good alternative therapy, which can be carried out if the MBO is not technically feasible or available."

MBBS, Dip. Ortho, DNB ortho, MNAMS

Dr Supreeth D R (MBBS, Dip. Ortho, DNB ortho, MNAMS) is a practicing orthopedician with interest in medical research and publishing articles. He completed MBBS from mysore medical college, dip ortho from Trivandrum medical college and sec. DNB from Manipal Hospital, Bengaluru. He has expirence of 7years in the field of orthopedics. He has presented scientific papers & posters in various state, national and international conferences. His interest in writing articles lead the way to join medical dialogues. He can be contacted at editorial@medicaldialogues.in.

Dr. Kamal Kant Kohli

Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751