Modified Brostrom procedure yields good to excellent anatomical reconstruction

Lee KT. Foot Ankle Int. 2011;32:153-157.

A modified Brostrom procedure without calcaneofibular ligament reconstruction produced good to excellent results in patients with chronic ankle instability, according to these retrospective results.

Kyung Tai Lee, MD, of Eulji University School of Medicine, and colleagues followed 30 consecutive patients with chronic ankle instability who underwent modified Brostrom procedures without calcaneofibular ligament reconstruction from March 1997 to June 1999. There were 25 men and 4 women with mean age of 23 years at the time of the operation. Twenty-four of 30 patients were high-level amateur or professional athletes. The mean follow-up was 10.6 years.

The surgical procedure consisted of anterior talofibular ligament imbrication with inferior extensor retinaculum reinforcement, the authors wrote.

To evaluate clinical outcomes, the investigators retrospectively reviewed clinical charts. They used the Hamilton scale, a visual analog scale and the AOFAS score at final follow-up to determine functional outcome.

At final follow-up, the mean AOFAS score was 91 and the mean VAS was 87. Twelve patients had excellent results, 16 had good results and two had fair results, according to the Hamilton classification. On the ipsilateral side, mean anterior translational values were 6.9 mm; on the contralateral side they were 6.1 mm.

Mean talar tilt angles were 3.0° for the ipsilateral side and 2.5° for the contralateral side. Out of 30 patients, 28 regained pre-injury activity levels.

“The long-term surgical results of the modified Brostrom procedure without calcaneofibular ligament reconstruction for chronic lateral ankle instability were good to excellent in terms of functional, clinical and radiographic assessments,” the authors wrote.

The major attribute of this study is its long-term results. The minimum follow-up in this group of patients is 10 years. For a study with that duration of minimum follow-up, it is admirable that there were 30 of the original 38 patients in the core group. It is of note that the authors have performed radiographic stress tests in their long-term follow-up patients together with subjective outcome measures previously established in the literature.

As the authors have pointed out, critique issues for the paper include the fact that radiographic stress testing was available only on the long-term follow-up and could not be compared to preoperative data. Though they used semi-quantitative clinical measurements for instability preoperatively, correlation of clinical instability with radiographic instability is quite variable in this writer’s experience.

The authors have emphasized that their technique involves an isolated reconstruction of the anterior talofibular ligament (ATFL). Whereas the distal portion of the calcaneofibular ligament (CF) is quite separate and distinct from the ATFL, separation is not distinct in the proximal portion of the lateral collateral ligaments at the attachment to the fibula. Tightening of the proximal portion of the lateral collateral ligaments probably influences the tension in the calcaneofibular ligament more than this article would suggest.

This study supports the widely based clinical experience that Brostrom-like procedures have a very high rate of success in short- and long-term outcomes.

– Ronald W. Smith, MD
Orthopedics Today Editorial Board member
Associate clinical professor
University of California, Los Angeles

Disclosure: He has no relevant financial disclosures.