Do

suture anchors enhance Anterior Talofibular Ligament repair in the Broström Procedure?

Anatomic Suture Anchor Versus the Broström Technique for Anterior Talofibular Ligament Repair. A
Biomechanical Comparison.

Norman E. Waldrop III MD, Coen A. Wijdicks, PhD, Kyle S. Jansson BS,
Robert F. LaPrade MD PhD, and Thomas O. Clanton MD


1. Describe the Case or Problem: Working with 6 different providers; each approaches the repair of the ATFL during the
Broström procedure in a different manner. Though the indications are the same, “instability with or without ankle pain”,
the question was to investigate whether the suture anchor was superior to a primary repair technique.

2. Literature Search: Article was found on American Journal of Sports Medicine through a literature search using Google
Scholar for keywords Broström repair techniques; while there are, many articles addressing Broström procedures for
treatment of chronic lateral ankle instability and or various techniques (i.e. arthroscopic primary repair); few studies report
on the strength of secondary repair methods, in particular suture fixation vs suture anchors.

a. 20-25% fail conservative treatment
b. 24 Cadavers, age range 29-69 years
c. Exclusion Criteria: age younger than 20, older than 70, evidence of prior ankle injury by direct inspection
d. Hypothesis: Suture anchor repair of ATFL would produce improved results compared with the standard Broström
technique with respect to both load to failure and stiffness.

3. Methods
a. This was a cadaveric research study designed to compare native ATFL stiffness and strength against load to failure
versus that of ATFLs repaired with suture or suture anchors. Specifically addressing the effect of a Broström
performed with No. 0 non absorbable continuously braided polyethylene/polyester multifilament sutures
(FiberWire Arthrex) or 3.0X14.5mm biocomposite (beta tricalcium phosphate/poly(L-Lactide co-DL-Lactide) suture
anchor (Bio-Suture Tak, Arthrex) which was loaded with same No. 0 non absorbable continuously braided
polyethylene/polyester multifilament sutures.
b. Cadavers assigned to random groups, ATFL Intact, Traditional Broström, Suture Anchor with Anchor on Fibula,
Suture Anchor with Anchor on Talus
c. Standard curvilinear incision anterior to fibula 3cm proximal to ATFL insertion extending along distal anterior
fibula. ATFL divided midsubstance for traditional Broström technique, near fibular insertion for suture anchor
fibula group, or talar neck for suture anchor talar neck group. Specimens then tested with anterior drawer test to
verify instability was created.

d. ATFL isolated with all soft tissue stripping from tibia and fibula, including muscle, with exception of ATFL
attachment from distal fibula to talar neck. Foot left intact with skin present. Afterwards, tibia removed along with
syndesmotic ligaments, PTFL, and CFL. Only fibula and ATFL remained in isolation for all specimens.
e. Instron E10000, foot placed in 20 degree inversion and 10 degree plantar flexion replicating tension in ATFL, with
fixated STJ to eliminate influence of rotational forces. 15N force for 10 seconds, held at 15N for 5 seconds, then
load to failure by pulling fibula at rate of 20mm/minute.
f. Ultimate Load to failure = maximum endured load during testing. Stiffness = slope of linear region of load-
elongation curve corresponding to the steepest straight line tangent to the curve.
g. Statistical analysis via Predictive Analytics Software, 1- way analysis of variance (ANOVA), post hoc Tukey Honestly
Significant Difference Test to identify statistically significant means between age groups.

 4. Critical Appraisal:

a. Only one type of suture used for both Broström and Broström-Suture Anchor technique.
b. Only one anchor used for either talar or fibular placement
c. 24 cadavers, average age 58.4, experiment only assesses at time 0 after procedures
i. NOTE: SUTURE TAPE is an alternative method separate from suture fixation, and remains the most
biomechanically advantageous repair method per studies conducted by Schuch, R. et al (Comparison of
Broström technique, suture anchor repair, and tape augmentation for reconstruction of the anterior
talofibular ligament) and Viens, Nicholas A. et al (Anterior Talofibular Ligament, Biomechanical
Comparison of Augmented Broström Repair Techniques with the Intact Anterior Talofibular Ligament).

5. Results
a. Ultimate load to failure and stiffness for Broström and suture anchor fibula or talus were significantly lower than
that of intact ATFL. All three repair groups NOT significantly different.
b. Mechanism of failure was at the ligament-suture interface for all specimens in all three groups. Mechanism of
failure for intact state was predominantly at distal attachment site, (4 of 6 specimens) with remainder of
specimens failing at midsubstance.
c. Suture anchor repair of ATFL fibular or talar is just as effective as Broström technique for restoring ATFL strength;
however, there is only about 42-49% of original strength in repaired specimens when compared to the native
intact ligament AT TIME 0. Thus, importance of protection from excessive stress for these repairs during the early
postoperative rehabilitation phase. Repairs rely heavily on healing of tissues to regain strength. Immobilization and
protective rehabilitation is key.

My Thoughts:
Though lateral ankle instability can be addressed with both surgical and conservative measures; when performing surgical repair the
option of primary repair and or suture anchors are common practice. This article does not validate one method over the other;
however, this may be because the article only utilizes one specific type of suture, with a particular tensile strength, used in both
primary repair or with the single suture anchor. I believe the study would need to assess a variety of suture material and anchors
from various manufacturers to provide a better answer. Such study should also aim to assess use of two or more anchors; a common
practice in Fort Bragg Orthopedic and Podiatric surgery. As a result, and due to a lack of such a study; I would choose to base my
operative decision on the mechanism of failure being a distal avulsion of the ligament vs midsubstance tear. If the ATFL tears closer
to the fibula or talus, I would utilize anchors at respective insertion points. If the ATFL presents with a midsubstance tear or in
patients with poor bone quality, I would opt for a primary repair. For our active duty military population or athletes, my preference
would be to proceed with Broströms involving the use of FiberTape, where studies have demonstrated ATFL load to failure and
stiffness to be equivalent to native ATFL. (Viens et al) or superior performance when testing angle at failure and failure torque
compared to native ATFL (Schuch et al).