Evolution in Surgical Management of Ankle Instability in Athletes

Brian C. Lau, MD; Alexej Barg, MD; C. Thomas Haytmanek, MD; Kirk McCullough, MD; Annunziato Amendola, MD


J Am Acad Orthop Surg. 2021;29(1):e5-e13. 

In This Article

Use of All-arthroscopic Stabilization

Increasing interest has been noted in an all-arthroscopic modified-Broström techniques. Proponents of the all-arthroscopic technique propose that the reduced surgical dissection results in less postoperative pain and swelling, higher patient satisfaction, and possible earlier rehabilitation while maintaining equal clinical results.[25–28]

A series of biomechanical studies demonstrated that an arthroscopic two-suture anchor Broström technique was equivalent to the open Broström in strength.[29,30] Giza et al[30] evaluated seven matched pairs of cadavers after an anatomic Broström repair with suture anchors done using either open or arthroscopic techniques. They found no difference between the two techniques in degrees to failure, torque to failure, or stiffness for the repaired ligament complex. Drakos et al[29] evaluated 20 matched lower extremity cadavers and used an Optotrak computer navigation system to measure changes in three planes. No statistically significant differences were found between the open or arthroscopic repair in total combined motion.[29]

Recent clinical studies on the arthroscopic Broström indicate recurrence rates ranging from 2.7% to 10%;[31–33] open Broström technique is reported to have a 5% to 10% patient dissatisfaction or recurrence rate.[17] In all studies evaluating the arthroscopic Broström, postoperative AOFAS scores or Karlsson-Peterson scores were improved from preoperative measurements.[31–34]

Arthroscopic techniques also have comparable patient-reported or radiographic clinical outcomes when compared with open techniques.[25] A systematic review and meta-analysis of clinical outcomes comparing the two techniques reported no statistically significant differences in VAS, AOFAS score, Karlsson Score, or talar tilt.[25] In the only randomized trial of the two techniques, Yeo et al[26] found no significant differences in clinical outcome scores or stress radiographs 1 year after the surgical procedure. Matsui et al[27] comparative review of outcomes after open (18 patients) or arthroscopic (19 patients) repairs reported no group differences in any recurrence in ankle instability, talar tilt angle, or displacement in stress radiographs. Although the time to return to daily activity was significantly shorter in the arthroscopic group (5.3 versus 7.1 weeks), no significant difference was noted in return to sports activity (16.5 versus 17.1 weeks, respectively).[27] They also found that in the early postoperative period (3 days), VAS scores were lower in the arthroscopic group but by 2 weeks VAS was similar for both groups. They also reported that surgical time in the arthroscopic group (after an initial 6 cases) had a mean duration of 29.6 minutes compared with 44.2 minutes in the open group.[27] Clinically, arthroscopic techniques seems safe with comparable results with the open procedure. In addition, the arthroscopic procedure has a shorter operating time and may facilitate earlier return to daily activities.

Techniques have been developed that include an arthroscopic approach with suture tape augmentation that may facilitate earlier return to play. Yoo et al[28] conducted an arthroscopic Broström with and without suture tape augmentation. In 85 consecutive patients (22 with suture tape augmentation and 63 without suture tape augmentation), AOFAS scores at 6 and 12 weeks after operation showed greater improvement in the suture tape augmentation group.[28] At 24 weeks, however, no differences were noted between groups. Regarding return to sport, at 12 weeks the arthroscopic suture tape augmentation group had an 81.8% return to sport rate compared with 27% in the isolated arthroscopic repair group.[28] All patients followed the same postoperative protocol including a compression bandage without a splint and progressive weight-bearing. At 2 weeks, formal physical therapy including proprioceptive training, active ankle extension, and eversion exercises was started. Running and return to high-contact sports (soccer and basketball) were allowed at 4 weeks. At no time points were there any differences in radiographic stress anterior drawer test or rate of complications.[28] Pellegrini et al[34] recently described a technique that uses a knotless modification of the arthroscopic Broström. Although this technique may facilitate earlier return to play, the clinical results remain pending.

One concern with the arthroscopic Broström technique is nerve entrapment, given the outside-in approach to suture passage through the extensor retinaculum and ligaments. Across a cohort of 233 patients across four studies, the reported rate of nerve injury (entrapment and neuritis) was reported in 2.1%.[31–34] Several studies have also defined a 4 to 5 cm safe zone for suture passage that is between the sural nerve and superficial peroneal nerve branch. Anatomic landmarks included the peroneus tertius and peroneus brevis tendon[35] (Figure 4).

Figure 4.

All-arthroscopic ankle stabilization safe zones: (A) demonstrating the internervous safe zone between intermediate branch of the superficial peroneal nerve and the sural nerve. B, Demonstrating an intertendinous safe zone between peroneus tertius and peroneus brevis. (1) Lateral malleolus, (2) peroneal tendon, (3) base of fifth metatarsal, (4) peroneal tertius, and (5) achilles tendon.

Arthroscopic techniques have biomechanical and clinical data comparable with open techniques. Several methods have been described with some requiring accessory portals, but the most commonly cited technique is that described by Acevedo and Mangone[35] that uses an outside-in technique to shuttle suture passage. A learning curve exists, but once proficiency is obtained, the arthroscopic Broström may lead to shorter surgical time. It is important to remember during the surgical procedure to keep suture passage within the internervous safe zone. Arthroscopic techniques may facilitate earlier rehabilitation and return-to-daily activities, but an earlier time to return to sport has yet to be documented.