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
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.
A small stab through the peroneal sheath at the distal most aspect of the fibula allows quick examination and protection of the peroneal tendons. If excessive, often discolored fluid is present or the integrity of the tendon is poor or tears are present, carry the incision proximally. Full visualization of the tendons is warranted.
Bluntly delineate the extensor retinaculum anteriorly and inferiorly, and tag it for later incorporation into the repair. Introduce a curved hemostat from the distal aspect of the fibula coursing parallel to the anterior border. This protects the peroneal tendons as well as the lateral talar cartilage as one transects the capsule and anterior talofibular ligament. Be sure to leave a cusp of tissue on the distal anterior aspect of the fibula. One should excise the impinging tissue in the lateral gutter or synovitis.
In addition, surgeons can drill visible lateral shoulder talar osteochondral defects and remove loose bodies. If the cusp of tissue is loose, usually from the presence of a loose body, one can reattach the tissue with an anchor in the area of the anterior talofibular ligament insertion onto the fibula.
Move the stack of towels to the forefoot to allow dorsiflexion and eversion of the foot. Employ multiple pants-over-vest sutures utilizing the residual anterior talofibular ligament and associated capsule. Throw all the sutures at once and then individually tie and tension them. Reef the extensor retinaculum up onto the cusp of tissue on the distal anterior aspect of the fibula. Close the subcutaneous tissue and skin in standard fashion. Place a posterior splint with the foot dorsiflexed and everted to support the repair.
When one performs this procedure in isolation, it is typically complete in less than 30 minutes with no assistance necessary.
It is to the surgeon’s benefit to remain as efficient as possible. Simple, often overlooked intraoperative maneuvers can facilitate ease of the procedure. Techniques such as foot position and choice of anesthetic administration during the case make the procedure flow smoother. A surgeon can gain “style” points for accomplishing procedures in a timely and effective manner when other surgeons may struggle.
Dr. Bussewitz is an Advanced Foot and Ankle Surgical Fellow at the Orthopedic Foot and Ankle Center in Westerville, Ohio.
Dr. Hyer is a Fellow of the American College of Foot and Ankle Surgeons. He is the Director of the Advanced Foot and Ankle Reconstruction Fellowship at the Orthopedic Foot and Ankle Center in Westerville, Ohio.
1. Brostrom L. Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures. Acta Chir. 1966; 132(5):551-565.
2. Bell SJ, Mologne TS, Sitler DF, Cox JS. Twenty six year results after Brostom procedure for chronic lateral ankle instability. Am J Sports Med. 2006; 34(6):975-978.
3. Hamilton WG, Thompson FM, Snow SW. The Modified Brostrom procedure for lateral ankle instability. Foot Ankle. 1993; 14(1):1-7.
4. Hennrikus WL, Mapes RC, Lyons PM, Lapoint JM. Outcomes of the Chrisman-Snook and modified-Brostrom procedures for chronic lateral ankle instability. A prospective randomized comparison. Am J Sports Med. 1996; 24(4):400-404.
For further reading, see “A Guide To Addressing Lateral Ankle Instability” in the December 2009 issue of Podiatry Today. To access the archives, visit www.podiatrytoday.com.