Issue: January 2022
Source: Coetzee JC, et al. Foot Ankle Int. 2018;doi:10.1177/1071100717742363.
Disclosures: Hsu reports being a paid consultant for Arthrex. Haghverdian reports no relevant financial disclosures.
January 14, 2022
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Broström suture tape lateral ankle ligament augmentation allows accelerated rehabilitation

Issue: January 2022
Source: Coetzee JC, et al. Foot Ankle Int. 2018;doi:10.1177/1071100717742363.
Disclosures: Hsu reports being a paid consultant for Arthrex. Haghverdian reports no relevant financial disclosures.
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Lateral ankle sprains are among the most common athletic injuries.

Most of these sprains will positively respond to nonoperative treatment consisting of a brief period of immobilization in a tall, controlled ankle movement (CAM) boot vs. brace, NSAIDs, ice, elevation and physical therapy. However, 10% to 20% of patients may ultimately fail conservative management and have symptoms of chronic pain with functional or mechanical instability necessitating surgical repair. The modified Broström technique for lateral ligament repair has been the standard operation for the management of chronic ankle instability.

Despite reports of clinical success, biochemical studies have demonstrated that repair of the tissue is weaker than the native anterior talofibular ligament (ATFL) and is subject to elongation after surgery. To protect the ligament repair, traditional postoperative protocols limit early mobilization and weight-bearing, which are known to promote collagen organization and healing. As a result, failure of the repair and recurrent instability have been reported in cohorts of patients with chronic pain and decreased function. Advances in lateral ligament reconstruction techniques have been shown to provide a reliable treatment for chronic ankle instability. Specifically, suture tape augmentation of the modified Broström technique can allow for favorable functional outcomes, accelerated rehabilitation and earlier return to preinjury levels of play without an increase in complication rate or morbidity.

Preoperative planning

Prior to surgery, a thorough history and physical examination are performed to identify any concomitant injuries, such as osteochondral lesions, peroneal tendon pathology and/or deltoid ligament sprain. Physical examination of gait, standing and sitting should be performed to evaluate for any forefoot or hindfoot abnormalities. Provocative examination maneuvers, such as the anterior drawer test, evaluate for ATFL instability. An anterior translation greater than 2 mm to 5 mm from the opposite side indicates instability, although the exam may be limited due to peroneal guarding in the conscious patient. A talar tilt test may be performed to evaluate for medial deltoid or calcaneofibular ligament (CFL) dysfunction with excessive eversion or inversion, respectively. Peroneal instability and posterior impingement should be carefully evaluated. External rotation or varus stress radiographs may be performed with fluoroscopy or traditional radiographs. MRI may be helpful to evaluate for peroneal tendon pathology, osteochondral lesions or syndesmotic injuries, particularly when considering ankle arthroscopy in conjunction with lateral ligament reconstruction.

Ankle arthroscopy

In the OR, the patient is positioned supine on a regular OR table. The operative leg is placed into a thigh holder and a nonsterile tourniquet is applied to the upper thigh. The patient is then prepped and draped in the usual sterile fashion. A noninvasive ankle distraction strap is placed over the heel and dorsum of the foot and attached to a sterile clamp and bar distraction device. The tibialis anterior tendon is identified and a 10-cc syringe with normal saline and an 18-gauge needle are used to insufflate the ankle joint just medial to the tibialis anterior tendon. A 1-cm skin incision is made with an 11 blade and a small hemostat is used to enter the joint. A 2.7-mm 30° arthroscope is inserted into the anteromedial (AM) portal and the anterolateral (AL) portal is established via direct visualization. A thorough arthroscopic examination of the joint is performed with direct inspection of the chondral surfaces, lateral ligaments, syndesmosis and deltoid ligament.

A 3.5-mm small joint shaver is introduced into the AL portal (Figure 1). Synovectomy and debridement are performed within the joint and lateral and AL gutters. Any loose bodies or osteochondral lesions can be addressed at this point. The arthroscopic portals are then closed with 3-0 nylon suture.

Ankle arthroscopy setup with the left lower extremity in a thigh holder is shown
1. Ankle arthroscopy setup with the left lower extremity in a thigh holder is shown. A noninvasive ankle distraction strap is placed over the heel and dorsum of the foot. A 2.7-mm arthroscope is shown in the AL viewing portal with a 3.5-mm shaver in the AM portal.

Source: Andrew R. Hsu, MD

Lateral ligament reconstruction

A longitudinal curved skin incision is planned over the anterior aspect of the distal fibula, in line with the peroneal tendons, allowing for access to the talar neck, peroneal tendons and calcaneofibular ligament (Figure 2). Dissection is performed through subcutaneous tissue carefully to the inferior extensor retinaculum, which is identified and saved for later imbrication (Figure 3). The peroneus brevis and longus tendons are then individually evaluated for tenosynovitis or tears and then carefully debrided of surrounding tenosynovitis and scar tissue. (Figure 4). The peroneal sheath is repaired at the end of the procedure to prevent iatrogenic tendon instability.

A curvilinear skin incision is planned over the distal fibula
2. A curvilinear skin incision is planned over the distal fibula in line with the peroneal tendons for extensile exposure if it is needed.
The inferior extensor retinaculum is identified
3. The inferior extensor retinaculum is identified and dissected for later repair.
The peroneal tendons are identified and individually evaluated for tenosynovitis or tears
4. The peroneal tendons are identified and individually evaluated for tenosynovitis or tears.

The ATFL and CFL are incised from their origin on the distal fibula. Full-thickness anterior and posterior cuffs of tissue are created and a small rongeur is used to create a bed of bleeding cancellous bone for direct ligament to bone healing. Two suture anchors are then drilled and carefully spaced out approximately 1 cm to 2 cm along the distal and anterior aspects of the fibula (Figures 5 and 6). The talar body is drilled with a 3.4-mm drill angled 40° to 45° from the sagittal plane and parallel to longitudinal axis of the foot (Figure 7). A lateral radiograph can confirm proper trajectory into the talar body. A 4.75-mm tap is used to prepare the bone tunnel for the 4.75-mm anchor (Figure 8).

A suture anchor is drilled and placed in the distal anterior aspect of the fibula
5. A suture anchor is drilled and placed in the distal anterior aspect of the fibula.
Two suture anchors are placed approximately 2-cm apart in the distal and anterior aspects of the fibula
6. Two suture anchors are placed approximately 2-cm apart in the distal and anterior aspects of the fibula.
The lateral talar body is prepared with a 3.4-mm drill
7. The lateral talar body is prepared with a 3.4-mm drill. The trajectory is carefully evaluated to avoid penetration into the ankle or subtalar joints.
A 4.75-mm tap is used to allow for the insertion of the double-loaded suture tape anchor
8. A 4.75-mm tap is used to allow for the insertion of the double-loaded SwiveLock suture tape anchor (Arthrex).

The InternalBrace suture tape-loaded anchor (Arthrex) is inserted into the lateral talar body (Figure 9). Next, the 3.4-mm drill is used to drill the area of the distal fibula between the previously placed anchors (Figure 10). A 3.5-mm tap is used to the prepare the anchor site. The ankle is dorsiflexed and a posterior force is applied with the ankle in eversion. The ATFL and CFL are repaired back to bone with the previously placed suture anchors (Figure 11).

The anchor is inserted into the lateral talus and confirmed to be flush with the bone
9. The anchor is inserted into the lateral talus and confirmed to be flush with the bone.
The distal fibula is prepared for the suture tape with a 3.4-mm drill
10. The distal fibula is prepared for the suture tape with a 3.4-mm drill.
Sutures are passed through ATFL and CFL tissues for the Broström repair
11. Sutures are passed through ATFL and CFL tissues for the Broström repair.

A bump is applied behind the ankle with the foot in approximately 10° plantarflexion and the suture tape is appropriately tensioned on top of the ligament repair. With the ankle in neutral dorsiflexion, a hemostat should easily be placed under the suture tape, confirming the joint is not over-constrained (Figure 12). The remaining inferior extensor retinacular tissue is imbricated with additional suture completing the repair (Figure 13). The wound is thoroughly irrigated with normal saline and closed in a layered fashion. A sterile soft dressing is applied followed by application of a tall CAM boot.

The 3.5-mm SwiveLock anchor is inserted into the distal fibula on top of the ligament repair
12. The 3.5-mm SwiveLock anchor is inserted into the distal fibula on top of the ligament repair for the suture tape augmentation.
The inferior extensor retinaculum is repaired with additional sutures
13. The inferior extensor retinaculum is repaired with additional sutures.

Accelerated rehabilitation

The patient is allowed to be weight-bearing as tolerated in a tall CAM boot for the first 3 weeks. Sutures are removed approximately 2 weeks after surgery. Patients are encouraged to start active plantar and dorsiflexion range of motion exercises out of the boot in the first 3 weeks. From weeks 3 to 6, patients begin a supervised physical therapy program. They should be full weight-bearing and transition to a regular shoe with a lace-top ankle brace during that period.

Passive ankle inversion is avoided. However, gentle range of motion exercises with active ankle plantar and dorsiflexion with toe flexion and extension are performed. From weeks 6 to 8, sport-specific exercises are initiated with the goal of full range of motion. Inversion and eversion exercises are allowed in this phase of rehabilitation. Agility training with proprioception exercises performed to achieve a single-leg stance on an even surface.

From weeks 8 to 12, sport-specific exercises are continued with the goal of full range of motion, agility and near full strength in the operative extremity. Return to play is allowed after this phase of rehabilitation is completed.

Outcomes

Suture-tape augmentation or InternalBrace of the modified Broström technique has been demonstrated to be at least as strong as the native ATFL in time zero testing in fresh-frozen cadaveric models. A retrospective analysis by J. Chris Coetzee, MD, and colleagues showed suture tape augmentation compared with a standard modified Broström allowed for an accelerated rehabilitation protocol with immediate weight-bearing and early range of motion.

In a multicenter, prospective, randomized trial by Robert Kulwin, MD, and colleagues, the authors demonstrated the average return to preinjury activity levels occurred approximately 4.2 weeks earlier in patients who underwent suture tape augmentation compared with patients who underwent a standard Broström without augmentation. Accelerated rehabilitation protocols were initiated with and without augmentation, however, a higher number of patients without augmentation necessitated transition to a standard rehabilitation program.

We currently perform Broström suture tape ligament augmentation for all of our patients with lateral ankle instability. We have successfully incorporated an accelerated rehabilitation protocol that allows patients to minimize immobilization time and return to baseline activities at 12 to 13 weeks after surgery without complications.

Editor's note

Ligament augment devices for lateral ligament instability reconstruction are proposed with the intent of improving an already good operation. The Broström procedure with the Gould modification has been the workhorse of lateral ligament reconstructions for more than 50 years.

Porter and colleagues showed in a prospective randomized study that the ligament augment device outperformed a standard Broström in clinical scoring and patient satisfaction at every time point during the 5-year study period. The ligament augment device used in this study is not available commercially in the U.S., but was described as a polyethylene synthetic ligament. This important study has placed ligament augmentation for lateral ligaments firmly in the playbook for many foot and ankle surgeons.

Synthetic ligament augment devices currently available and indicated for lateral ligament stabilization include polyester implants (prototype is the InternalBrace described herein) and knitted polyurethane-urea copolymer (prototype is the Artelon manufactured by Artelon). The surgical technique is similar with the differentiating factor being the flexibility of the textile. There are currently no comparative studies on the two versions of ligament reconstruction materials, with both showing great promise.

Gregory C. Berlet, MD, FRCS(C), FAOA
Orthopedics Today Section Editor, Foot & Ankle