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Modified Brostrom-Gould Procedure

synonyms:

Brostrom-Gould CPT

  • 27698(repair, secondary, disrupted ligament, ankle collateral)

Brostrom-Gould Indications

  • Chronic symptomatic lateral ankle instability that has failed to repond to non-operative management including rehabilitation and bracing.
  • Acute third-degree ankle sprains (high-level athletes)

Brostrom-Gould Contraindications

  • Fixed heel varus (concomitant valgus osteotomy required)
  • Severe tibiotalar varus alignment (require valgus distal tibial osteotomy)
  • Obesity
  • Large athletes (>250 pounds): concomitant Evans repair indicated
  • Peroneal weakness (peroneal nerve pasly, Charcot-Marie-Tooth disease)

Brostrom-Gould Alternatives

  • Evans procedure: tenodesis of the peroneus brevis tendon to the fibula, by directly suturing the tendon to periosteum or securing the tendon to the posterior fibula through a bone tunnel. Restricts subtalar motion.
  • Watson-Jones procedure: reroutes the peroneus brevis tendon from posterior to anterior through the fibula and then back through the neck of the talus and sutured back on itself. Restricts subtalar motion.
  • Chrisman and Snook procedure: split peroneus brevis tendon brought from anterior to posterior through the fibula and down to the calcaneus through bone tunnels. Limits ankle and subtalar motion. (Snook GA, JBJS 1985;67Am:1).
  • Colville procedure: split peroneus brevis tendon used to reconstruct the ATFL and CFL in an anatomic fashion without limiting subtalar motion. (Colville MR, AJSM 1992;20:594)
  • Anderson procedure: plantaris tendon to used anatomically reconstruct both lateral ligaments without limiting subtalar motion (Anderson ME, JBJS 1985;67A:930)

Brostrom-Gould Pre-op Planning / Special Considerations

  • Consider concurrent ankle arthroscopy. Up to 95% of patients undergoing surgery for lateral ankle instability may have associated intra-articular pathology. (Ferkel RD, Foot Ankle Int 2007;28:24).
  • Strongly consider concurrent lateralizing calcaneal osteotom fro patietns with hindfoot varus deformity (Kuhn MA, Foot Ankle Int 2006;27:77).

Brostrom-Gouls Technique

  • Pre-operative antibiotic
  • Anesthesia
  • Well-padded tourniquet placed high on the thigh
  • All bony prominences well padded
  • Prep and drape
  • Perform ankle arthroscopy and treat any identified patholgy.
  • Leg exanguinated with eschmar bandge and tourniquet inflated
  • Curvilinear incision along the anterior border of the distal fibula
  • Preserve or ligate lesser saphenous vein. Preserve Sural nerve if encountered
  • Dissection down to joint capsule along the anterior border of the lateral malleolus, preserving a cuff of tissue on the fibula
  • Identify anterior talofibular and calcaneofibular ligaments or their remnents
  • Reef/repair ligaments and capsule using 2-0 nonabsorable suture in pants over vest configuration
  • Lateral portion of extensor retinaculum identified and mobilized.
  • Extensor retinaculum sutured into the cuff of tissue on lateral malleolus reinforcing the repair
  • Examine ankle for stability and full ROM
  • Irrigate wound
  • close

Brostrom-Gould Complications

  • Wound breakdown
  • Infection
  • Sural nerve injury / neuroma
  • Instability / Recurrence
  • Stiffness / Overtightening
  • CRPS

Brostrom-Gould Follow-up

  • 91% Good to excellent results at 26 years for the Brostom procedure (Bell SJ, AJSM 2006;34:975)
  • Late reconstruction for lateral ankle instability is successful in approximately 85% of patients regardless of the type of reconstruction performed. (Colville MR, JAAOS 1998;6:368)
  • 2 weeks post-op: Place in a removable ankle-foot orthosis and begin active exercise program to regain motion and strength. Passive inversion stretching is avoided.
  • 6 weeks post-op: Lace-up style ankle brace for daily activities. Progressive resistive and proprioceptive exercises continued for the next 2-4 months.
  • 3 months post-op: Cutting and pivoting sports resumed, brace is worn for sports for 6 months.
  • Athletes continue to use a brace or taping for sports indefinitely.

Brostrom-Gould Outcomes

Brostrom-Gould Review References

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