Broström procedure

Broström procedure
Intervention
ICD-9-CM	81.49

The Broström operation is a repair of ligaments on the outer ("lateral") side of the ankle. It is designed to address ankle instability. More importantly, it is primarily used to repair the ATFL (anterior talofibular ligament) in the ankle. It is thought that the majority of patients regain most function in their ankles. The recovery time for the procedure varies according to the patient but usually takes a minimum of 3–6 months. ^[1]

Purpose

The purpose of this procedure is to stabilize the ankle, improve the ankle's mechanics and restore full function. This procedure also aims to help a patient reduce pain related to their injury and ankle sprains, as well as to avoid early arthrosis. Many patients who have this procedure will also notice that they experience ankle sprains far less often. Some patients will experience no ankle sprains after this procedure unless they experience a trauma to their ankle.

Description

During a Broström procedure the patient will be put to sleep under general anesthesia. Once asleep the surgeon will thoroughly clean the area that will be operated on. They will then make all necessary incisions. Once the incisions are made they will repair any damaged lateral ankle ligaments in the hope of restoring the ankle back to its pre-injury state. This procedure can also include shortening and reattaching the lateral ligaments to reconstruct them. Once all of the repairs are made the surgeon will suture the incisions and apply any necessary bandages. Sports Medicine Surgeons will also take care of any side pathologies.

Surgical Technique: (http://www.wheelessonline.com/ortho/modified_brostrom_procedure)^[2] Incision is made over border of lateral malleolus; peroneal tendon exploration would require a posterolateral longitudinal incision; Surgeons care for peroneal tendons, sural nerve and lesser saphenous vein (which might be ligated), and branches of the superficial peroneal nerve; Proceeding thru subcutaneous tissue, identify and preserve the inferior extensor retinaculum; - this is mobilized for later attachment to the anterior edge of the fibula; - identify the ATFL,if it is torn, it is usually torn from the fibula; - make anterior capsular incision, leaving a small cuff of tissue, identify the CFL at the inferior tip of the fibula;ankle is then placed in valgus and dorsiflexion, and the redundancy of the ligament is assessed; sutures are passed thru the proximal edges of the ATFL and CFL; drill holes are made in the distal fibula; sutures are passed thru the drill holes, and are tied; the posterior edge of the extensor retinaculum is then opposed to the anterior edge of the fibula;

Post op care: - Standard involves 6 weeks of casting, but there is some evidence that there are better functional results with 3 weeks of casting.

^[3][4][5][6]

Possible Complications

Since this is a surgical procedure complications can occur. Some patients may experience an infection at the incision site. If an infection occurs, they can almost always be cured with a course of oral antibiotics. Another complication is superficial peroneal nerve distribution sensation reduction. Generalized ligaments laxity may also occur. The over-tightening of ligaments may happen, although the implications of such over-tightening have yet to be studied. In some cases, the Brostrom repair has greatly decreased the patients' abilities to walk. Brostrom repair success rates tend to be over-estimated and are typically based on surgeons' reports of their patients rather than on long-term studies of the patients' self-reporting of improvements--or lack thereof. Since anaesthesia is used there is a chance of anaesthesia complications including adverse reactions or allergic reactions. A Brostrom repair should be considered a last resort after a patient has tried a series of non-surgical options, such as wearing a boot cast after the injury, going to physical therapy for an extended period of time, etc. Most ankle sprains can significantly improve without surgery.

Outcome

Those who have had this procedure done are expected to have a stronger ankle, meaning their ankle will no longer give out on them. It is estimated that most patients who have this procedure experience restored stability. Success can be achieved regardless how soon the ankle is repaired after a patient's ankle instability issues occur, but the results are slightly better when the surgery is performed sooner. According to another study, most patients reported good to excellent results. Their ankles felt stable, and after they completely recovered, they noticed improved stability and significant restoration of function. Any pre-existing arthritis stage in upper or lower ankle joints will not be changed through this procedure and may act as fact in decision making of pros and cons.

References

1. Bell S, Mologne T, Sitler D, Cox J (2006). "Twenty-six-year results after Broström procedure for chronic lateral ankle instability". The American journal of sports medicine 34 (6): 975–8. doi:10.1177/0363546505282616. PMID 16399935.
2. Duke, Orthopaedics. "Wheeless' Textbook of Orthopaedics". Duke Orthopaedics. Retrieved 2 May 2013.
3. "Sprained ankles." Brostrom, L. Acta Chir. Scand. Vol 132. 1966. p 551-565.
4. "The Modified Brostrom Procedure for Lateral Ankle Instability." W.G. Hamilton MD et al. Foot and Ankle. Vol. 14, No. 1/ Jan. 1993.
5. "Ankle Instability Repair: The Brostrom-Gould Procedure", W.G. Hamilton (Master Techniques in Orthopaedic Surgery. The Foot and Ankle.) Raven Press, Ltd. New York, 1994.
6. "Clinical Instability of the Modified Brostrom Evans Procedure to Restore Ankle Instability." P. Girard MD et al. Foot and Ankle Instability. Vol 20. No 4. Apr. 1999. p 246