How To Enhance Efficiency With The Modified Brostrom Ankle Stabilization

Author(s): 
By Bradly W. Bussewitz, DPM, and Christopher F. Hyer, DPM, FACFAS

Operating room (OR) efficiency does not happen by accident. The ability to synchronize anesthesia, the OR staff and junior physicians can take the attending surgeon great time, effort and diplomacy within the hospital or surgery center. At the center of the efficient model is the surgery itself. The surgeon must have a procedural template to help maneuver and facilitate the ease of each given procedure.

   Accordingly, we offer some of our technical pearls to help create reproducible surgery when performing the modified Brostrom ankle stabilization. Surgeons may perform the Brostrom ankle stabilization to treat ankle instability.1 The procedure has proven results and high patient satisfaction.2-4

Pertinent Anatomical Considerations

The anterior talofibular ligament is a separate structure from the anterior ankle capsule that covers its superficial surface. The anterior talofibular ligament is responsible for restraining the talus from anterior subluxation within the ankle mortise. Acute or chronic trauma can create a ligament/capsule complex that becomes attenuated (a grade I or grade II injury) or a complete rupture, which is a grade III injury. Also, systemic collagen disorders such as Ehlers-Danlos syndrome or Marfan syndrome can create generalized ligament laxity. This results in lateral ankle instability and pain.

   The senior author’s surgical technique aims at imbricating the anterior tissues, both the capsule and the anterior talofibular ligament, and adding the extensor retinaculum or Gould modification.

   Operative efficiency begins before the patient arrives in the OR. The patient goes to the operating room following a regional popliteal block under anesthesia in the preoperative bay. This allows for an expedited procedure, quicker discharge from the post-anesthesia care unit and reliable pain control for many hours. General anesthesia allows patient tolerance of a thigh tourniquet. This is important so the soft tissues of the lower leg are not constricted, which may interfere with appropriate mobilization of soft tissues during the repair.

   Position the patient in the lateral decubitus position with the operative limb up, employing either a beanbag or kidney supports, depending on the facility standards. One should ensure the operative limb has a slight bend and is angled in a posterior direction. The non-operative limb is inferior and anterior in a more straight position. All bony prominences (proximal and distal fibula) should be appropriately protected with gel pads.

   Prep and drape the surgical limb. Be sure to keep the drape well above the surgical site to allow full visualization of the lower leg and extension of the incision proximally if peroneal pathology exists. If you suspect peroneal pathology based on the preoperative exam and/or magnetic resonance image (MRI) findings, start the incisional approach just proximal to the tip of the fibula and softly arc the incision anterior to the sinus tarsi, stopping short of the lateral branch of the superficial peroneal nerve. This nerve is often visible subcutaneously by plantarflexing the fourth toe.

   When there is no suspicion of peroneal pathology, one can use a classic Ollier incision over the course of the anterior talofibular ligament. Place a stack of towels beneath the hindfoot to allow the forefoot to arch medially (internally), putting the lateral soft tissue on stretch. This allows for ease of tissue differentiation and tissue transection.

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