Journal of Orthopaedic Surgery 2007;15(3):306-10

Modified Brostrom-Evans-Gould technique for recurrent lateral ankle ligament instability
ZD Ng, S Das De
Department of Orthopaedic Surgery, National University of Singapore, National University Hospital, Singapore

ABSTRACT Purpose. To review the outcome of the modified Brostrom-Evans-Gould technique in patients with chronic lateral ankle ligament instability. Methods. Between August 2003 and June 2005, 20 men aged 19 to 35 (mean, 23) years with chronic lateral instability affecting 21 ankles, underwent the modified Brostrom-Evans-Gould technique by a single surgeon. The mean follow-up period was 12 (range, 6–20) months. Patients were assessed preoperatively and postoperatively using the Kaikkonen Ankle Scoring Scale. Results. Preoperatively, all patients had poor scores (<50). Postoperatively, 17 (81%) of the ankles attained excellent scores (85–100) and 4 (19%) attained good scores (70–84). Conclusion. The modified Brostrom-Evans-Gould technique appears effective for chronic lateral ankle ligament instability, particularly in the Asian

population with a higher prevalence of generalised joint hyperlaxity.
Key words: recurrence joint instability; lateral ligament, ankle;

INTRODUCTION Ankle sprains are common, particularly in athletes. Those involving the lateral ligamentous complex of the ankle constitute 85% of all such sprains. The anterior tibiofibular ligament is damaged 3 times more commonly than the calcaneofibular ligament,1 due to (1) the injury mechanism (the ankle is usually plantar flexed during the inversion strain) and (2) the relative weakness of the anterior talofibular ligament as compared with the calcaneofibular ligament.2 Though most patients recover well with conservative treatment and rehabilitation,3,4 10 to 20% develop chronic instability caused by repeated inversion injuries, resulting in pain, swelling,

Address correspondence and reprint requests to: Prof Shamal Das De, Department of Orthopaedic Surgery, National University of Singapore, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074. E-mail: dosdasde@nus.edu.sg

physical examination including anterior drawer test. Under either regional or general anaesthesia. The tendon graft was tensioned with the ankle in a neutral position and then tenodesed to the lateral malleolus. the stitches and the backslab were removed. the oblique-anteroposteriorly directed drill hole in the distal fibula (B). Then. 2 in muscle strength (rising on heels and toes). The indications for surgery were based on symptoms. peroneal muscle weakness. A fibreglass short-leg walking cast was applied for a further 4 weeks. 15 No. and the position of peroneus brevis (C). Four patients (involving 4 ankles) who did not have any major complications and were apparently satisfied with the outcome were lost to follow-up. The anterior talofibular ligament was exposed by dissecting the anterior tissues to access the front of the ankle. patients were placed in a lateral position.11 Gould12 modified the procedure by mobilising the ankle inferior extensor retinaculum and suturing it to the distal fibula over the ligamentous repair. 12) months and their preoperative and postoperative Kaikkonen Ankle scores assessed. and sometimes bruising over the lateral ligament. with the proximal half divided and split for 5 cm and passed through an obliqueanteroposteriorly directed drill hole. and tenderness over the lateral ankle. December 2007 Surgery for recurrent lateral ankle ligament instability 307 tenderness.10 Surgery is indicated when conservative management fails to produce a satisfactory functional outcome.6 Many patients may be asymptomatic between recurrences. flap over the anterior fibula.7 Healing of the torn ligament with weak fibrous tissue or in an elongated fashion could account for chronic instability. and instability of the subtalar joint. All patients had a history of repeated ankle sprains and a preceding traumatic ankle inversion injury and at least 3 months of preoperative physiotherapy (most were in military service). 23) years with chronic lateral ankle instability (one injured bilaterally. The modified Brostrom-Evans-Gould technique is a hybrid of both. The peroneus brevis tendon was isolated. A 5 to 6 cm curvilinear incision was made posterior to the lateral malleolus. tenderness. The remaining 20 patients (involving 21 ankles) were followed up for 6 to 20 (mean. After 2 weeks. The recurrence rate for lateral ankle sprains can be as high as 80%. one in balance (balancing on a square beam). The Evans procedure involves anchoring of the peroneus brevis tendon to the fibula. with the leg prepared and draped and a tourniquet was applied. The anterior Brostrum repair was further reinforced with the inferior extensor retinaculum (Gould procedure). and 2 in physical function (range of movement in dorsiflexion and ankle laxity by . The Kaikkonen Ankle Scoring Scale14 comprised 9 parameters: 3 in subjective assessments (symptoms. 24 male patients aged 19 to 35 (mean.8 So too could proprioceptive deficit. This included active ankle range of movements and muscle strengthening exercises.13 We aimed to review the outcome of the modified Brostrom-Evans-Gould technique used in patients with chronic lateral ankle ligament instability. taking care not to damage the sural nerve (Fig. respectively) underwent the modified Brostrom-Evans-Gould procedure by a single surgeon. 3. and swelling. Postoperatively. MATERIALS AND METHODS Between August 2003 and June 2005.). the cast was removed and a rehabilitation programme lasting 2 to 3 months was initiated. 11 and 12 injured the left and right ankles. and progressed to more vigorous activities such as brisk walking. varus tilt test. ability to walk and run). Radiographs did not reveal any bony avulsion or osteochondral fracture.5. while others have persistent pain. thus limiting inversion of the foot. one in functional stability (walking down a staircase). It involves shortening and imbricating the damaged elongated lateral ankle ligaments. the patient was placed in a wellpadded posterior plaster backslab with the ankle held in a neutral position with slight eversion. Surgeries are classified as either anatomical reconstructions using direct repair or non-anatomical reconstructions by tenodesis procedures.9. The transverse ligament was cut and double-breasted with a periosteal B C A Figure The line of incision is posterior to the lateral malleolus (A). This reinforces the repair and limits inversion.Vol.

8 0 (0) 5 (24) 16 (76) 1. none attained fair or poor scores (Table). there is a clear relationship between mechanical and functional instability. the anterior talofibular ligament is torn. The posterior talofibular ligament. Preoperatively.7 0 (0) 10 (48) 11 (52) 2. and descend stairs normally. per minute) >40 (10) 30–39 (5) <30 (0) Mean score Single-limb stance (seconds) >55 (10) 50–55 (5) <50 (0) Mean score Laxity of the ankle joint. run.0 Journal of Orthopaedic Surgery as poor (Table). for which surgery may be indicated.5 15 (71) 5 (24) 1 (5) 8. anterior drawer (mm) ≤5 (10) 6–10 (5) >10 (0) Mean score Dorsiflexion ≥10º (10) 5º–9º (5) <5º (0) Mean score No. 50 to 69 as fair. ankle foot orthoses. 70 to 84 as good. Ten ankles had limited inversion but none had limited eversion. No ankle had any swelling or tenderness.15.308 ZD Ng and S Das De Table Mean pre. ≥4) anterior drawer test). 17 ankles attained an excellent score and 4 a good score.5 19 (91) 2 (10) 0 (0) 9. being the strongest of the 3 ligaments making up the lateral ligamentous complex. Mechanical instability refers to weakening or laxity of the ligaments caused by structural damage to the connective tissue. RESULTS 19 patients (20 ankles) were satisfied with the outcome.0 5 (24) 10 (48) 6 (29) 4. subjective opinion about the recovery. only one symptom present.8 20 (95) 1 (5) 14. Functional rehabilitation involves restoration of range of movement and strengthening of muscles. one with stiffness.3 * Pain. followed by the calcaneofibular ligament.8 Postoperation 11 (52) 10 (48) 0 (0) 0 (0) 12. The final score correlates significantly with the isokinetic strength of the ankle. all 21 ankles had poor Kaikkonen scores (<50): 19 presented with pain. tenderness or giving way during activity (mild. is rarely injured.4 6 (29) 15 (71) 0 (0) 6. As the injury progresses. In patients with recurrent lateral ankle instability. 10 with tenderness. and <50 . swelling. most ankle sprains are managed conservatively.0 20 (95) 1 (5) 9.2 0 (0) 9 (43) 12 (57) 2. DISCUSSION The mechanism of the lateral ligamentous complex injury of the ankle involves inversion and supination of the plantarflexed foot. Scores of 85 to 100 are rated as excellent. Initially the anterolateral capsule is torn. 10 to 20% of the ankles develop chronic ankle ligament instability. and subjective functional assessment. experienced fewer symptoms. of ankles (%) Preoperation 0 (0) 2 (10) 16 (76) 3 (14) 4. and were able to walk. 2 to 3. Only 2 ankles had residual pain. and 15 with a sensation of ‘giving way’. 6 had some degree of stiffness. Postoperatively. per minute) >40 (10) 30–39 (5) <30 (0) Mean score Rising on toes (No. and 3 had the symptom of ‘giving way’. taping techniques as well as proprioceptive and coordination exercises. moderate. 18 with swelling. and severe.1 1 (5) 14 (67) 6 (29) 3.8 14 (67) 7 (33) 0 (0) 8. Functional instability refers to the subjective sensation of ‘giving way’ and joint instability due to peroneal muscle weakness.3 0 (0) 21 (100) 0.4 16 (76) 5 (24) 0 (0) 8. There were no problems with wound healing or infection when the cast was removed. All patients had improvement in their Kaikkonen scores.3 15 (71) 6 (29) 0 (0) 8. one was dissatisfied due to stiffness.16 Initially.and post-operative Kaikkonen Ankle scores of the patients Kaikkonen parameters (score) Symptoms* No (15) Mild (10) Moderate (5) Severe (0) Mean score Walk normally Yes (15) No (0) Mean score Run normally Yes (15) No (0) Mean score Walking down 44 stairs (seconds) <18 (10) 18–20 (5) >20 (0) Mean score Rising on heel (No. Ankle laxity was significantly improved. stiffness.6 17 (81) 4 (19) 0 (0) 9. Despite treatment.6 21 (100) 0 (0) 15.

and results in minimal complications and good surgical outcomes. as opposed to using the entire tendon. they can be difficult. This confers greater stability than using the Brostrom’s repair alone. using all or part of the peroneus brevis tendon for tenodesis.16:501– 11. Bonnin JC. Sports Med 2000. and confer greater anterior stability.47:661–8. Only 40% with moderate ligamentous laxity did well. Freeman MA.26 Gould12 reinforces the ligamentous repair by mobilising and suturing the inferior extensor retinaculum to the distal fibula.10. Jorgensen JP. Rupture of the lateral ligaments of the ankle: operation or plaster cast? A prospective study. 3. December 2007 Surgery for recurrent lateral ankle ligament instability 309 More than 60 different surgical techniques have been described for the treatment of chronic lateral instability of the ankle. Harrington KD. thereby offering better cosmesis and less morbidity and pain. Andersen SB. Jurik AG. de Carvalho A. but only 68% without generalised ligamentous laxity did so. J Bone Joint Surg Br 1965. Treatment of ruptures of the lateral ligament of the ankle. 6. which risks decreasing eversion strength. 86% of the patients without generalised ligamentous laxity achieved excellent or good functional results. Anderson A. Therefore. Funder V. Am J Sports Med 1988. which renders the standard Brostrom’s repair alone less effective. by limiting physiological ankle and subtalar motion.23 Moreover. ChrismanSnook. This limits inversion and stabilises the subtalar component. Surgical treatment of lateral ankle instability syndrome. 15 No. Patients undergoing a Brostrom repair had better functional and cosmetic results.24 some long-term studies indicate that normal mechanical stability is not restored. However.22. Poor results are mostly confined to patients with long-standing instability.9 These procedures avoid donor tendon sacrifice. 1. A modified Evan’s procedure using half of the peroneus brevis tendon harvested for tenodesis limits the postoperative decrease in the range of movement and eversion strength. CONCLUSION The modified Brostrom-Evans-Gould technique appears effective for chronic lateral ankle ligament instability. are technically easier. The Watson-Jones.37:282.12. as they have a higher prevalence of generalised joint hyperlaxity.19 The main drawback of tenodesis procedures is that the lateral ligaments are not reconstructed anatomically thereby restricting the postoperative range of movement. Acta Orthop Scand 1988. we had assessed the optimal method of ligamentous reconstruction. The hypermobile ankle. and Evans techniques are examples. 7. thereby predisposing to later degenerative changes. Comparison of three different treatments for ruptured lateral ankle ligaments. 4. particularly dorsiflexion and movement of the subtalar joint. Proc R Soc Med 1944. However. 34% had fair results due to excessive tightness and restricted range of movement. . In the former group. Anatomic reconstructions using the ruptured ends of the ligaments to restore stability have gained popularity.61:354–61. generalised hyperlaxity. part or all of the peroneus brevis (an evertor that stabilises the distal ankle) is sacrificed. In the latter group. et al. and 14% attained fair results (due to subsequent stretching out and subtalar instability). Degenerative arthritis of the ankle secondary to long-standing lateral ligament instability.Vol.9 The torn ligaments are often inadequate and not strong enough for anatomic reconstruction. The main incision is only 5 to 6 cm. Wethelund JO. Lindholmer E.25 Such repair was initially described by Brostrom11 and later by Gould12 and Karlsson et al.9 Success rates with good to excellent results ranged from 82 to 87%. J Bone Joint Surg Am 1979.18.30 62 patients with chronic lateral ankle ligament instability for at least 6 months underwent either the Brostrom repair or the tenodesis procedure. DiRaimondo CV. The procedure is relevant to Asian populations. 2.21 Other possible disadvantages include: failure to control anterior talar translation and rotatory instability. In view of the prevalence of generalised joint laxity REFERENCES in Asians (17% in a Singaporean population27 vs 10% in Caucasians28 vs 14. Sammarco GJ. we decided to perform a modified Brostrom-Evans-Gould procedure in nearly all patients with chronic lateral ankle ligament instability.1% in an African population29). restore normal anatomy. Functional instability following lateral ankle sprain. In addition. this procedure should be avoided in Asian patients with moderate generalised ligamentous laxity. in comparison to direct anatomical repair. 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