1. Development of Anatomic (Broström) repair
Tightening of the restraining tissues on the lateral side of the ankle (and subtalar joint)
Mid-substance imbrication of ATFL +/- CFL - Broström (1966)
Location ?
Detachment at origin and proximal reattachment of ATFL +/- CFL - Broström (1966); Karlsson (1988)
ATFL alone
How many ligaments ?
ATFL + CFL
Ligament suturing - Broström (1966)
Fixation ?
Osseous tunnels - Broström (1966); Karlsson (1988); Murphy (1999)
Lat TC lig – Broström (1966)
Bone Anchors and Suture Bridges – Paden (1994); Li (2009); Curry (2011)
Synthetic – Internal Brace - Mackay (2012)
Free edge of IER – Gould (1980)
Augmentation ?
Fibula periosteum – Kuner (1986); Zwipp (1990); Sjolin (1991)
Tendon autograft
Open – various incisions
Patient positioning
Tendon allograft
Thermal capsular shrinkage – Berlet (2002)
Modifications ?
Arthroscopic Broström-Gould with anchors – Acevedo (2011); Minimally invasive - (Cho,2015)

2. My own “lateral ligament journey”
1980s
Evans
Watson-Jones
Art Bolland
1987
Broström-Gould
Harvard
1994
Colville
1990s
Jón Karlsson modification
Periosteal augmentation > tri-laminar reconstruction
2013
Augmentation with Internal Brace (Mackay)
Mitek
c. 2000
Bone Anchors
Arthrex

3. Broström open incision - Options
Posterolateral
Gould, 1980
Karlsson, 1988
Et-Titi, 1995
Anterolateral
Broström, 1966
Horibe, 1991
Murphy, 1999
Greer Richardson, 2001
Lee, 2011
Straight lateral
Mahajan, 2009
Transverse curved lateral
Li, 2009

4. Broström - Arthroscopic
Arthroscopy Portals
Small anterolateral stab incisions for suture retrieval

5. Location of Lateral Ligament Tightening
Broström – Mid-substance shortening
or origin re-fixation
Karlsson – Detachment at origin
Broström L. Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures. Acta Chir Scand 132:
Karlsson J, Bergsten T, Lansinger O, Peterson L. Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. JBJS(Am)1988;70(4):

6. Broström repair – ATFL alone or with CTFL?
ATFL + CFL
ATFL +/- CFL
ATFL alone
Murphy (1999)
Osseous tunnels
Li (2009)
Bone anchors
Karlsson (1988)
45% ATFL + CFL
55% ATFL only
Broström (1966)
98% ATFL only (2% ATFL + CFL)
Lee (2011)
28/30 restored to pre-injury activity levels
Vector of IER and CFL indicated on arrows
Should we leave CFL alone (Lee, 2011)?
IER replaces CFL vector
Lee KT, Park YU, Kim JS, Kim JB, Kim KC, Kang SK. Long-Term Results After Modified Brostrom Procedure Without Calcaneofibular Ligament Reconstruction. Foot Ankle Int ;32(2):
Murphy GA. The modified Bröstrum technique for reconstruction of chronic lateral ligament instability. Operative Techniques in Sports Medicine 1999;7(1):36-40.

7. Fixation for Broström – Bone Tunnels
Ribbans. October 2015
Fixation for Broström – Bone Tunnels
Osseous Tunnels
- Lennart Broström (1966)
- Jón Karlsson (1988)
- Andrew Murphy (1999)
“….corner locking sutures on the horizontal mattress sutures provide a firmer grip on the ligament.” (than bone anchors)
Richardson EG. Operative Techniques in Sports Medicine 2001;9(1):26-31.
Cho B-K, Kim Y-M et al. Comparison between suture anchor and transosseous suture for the modified Broström procedure. FAI 2012;33(6):
“Both suture anchor and transosseous suture….effective….methods for chronic lateral instability”. Cho B-K et al. FAI. 2012

8. Fixation for Broström – Suture Anchors
GII™ De Puy Mitek Anchor
2.4 x 8.8mm titanium anchor
Pre-loaded with ORTHOCORD Suture
WJR Comments:
Anchors unforgiving because of barbs and difficult to reposition and/or remove
Suture material heavier - often palpable subcutaneously
Li X, Lin TJ ,Busconi BD. Treatment of chronic lateral ankle instability: a modified Broström technique using three suture anchors. Journal of Orthopaedic Surgery and Research 2009, 4:41 doi: / X-4-41.

9. Fixation for Broström – Suture Anchors
Arthrex anchors
Usually 2 anchors
+/- 1 specifically for CFL
Self-drilling
Better holding power than barbed anchors
Easier removal
Fiberwire is nonabsorbable, very strong material in smaller size

10. Uppsala Question Time
On completing, your Broström surgical repair (ATFL/capsule only with no Gould modification), how strong is your repair compared to the healthy ligament (measured in load to failure)?
c.25% of normal
c.50% of normal
c.100% of normal
c.150% of normal

11. Uppsala Question Time
On completing, your Broström surgical repair (ATFL/capsule only with no Gould modification), how strong is your repair compared to the healthy ligament (measured in load to failure)?
c.25% of normal
c.50% of normal
c.100% of normal
c.150% of normal

12. Strength of Broström repairs
Load to failure
(in Newtons)
Waldrop NE 3rd, Wijdicks CA, Jansson KS, LaPrade RF, Clanton TO. Anatomic suture anchor versus the Broström technique for anterior talofibular ligament repair: a biomechanical comparison. Am J Sports Med Nov;40(11): doi: / Epub 2012 Sep 7.
Viens NA, Wijdicks CA, Campbell KJ, LaPrade RF, Clanton TO. Anterior Talofibular Ligament Ruptures, Part 1: Biomechanical Comparison of the Augmented Broström Repair Techniques with the intact Anterior Talofibular Ligament. AJSM 2014;42(2):
Waldrop NE. AJSM. 2012;40(11): ; Viens NA et al. AJSM. 2014:42(2);

13. Fixation for Broström Arthrex Suture Bridge
Larger footprint on fibula for attachment of ligament
Increased strength for anchor pullout
5 anchors provide 37% greater torsional rigidity than 3 anchors
Allows for potentially earlier rehabilitation
Curry EE. Brostrom-Gould Lateral Ankle Ligament Reconstruction With Suture Bridge Modification Techniques in Foot & Ankle Surgery. September 2011;10(3):105–110.

14. Broström and Gould (1980)modification
Ribbans. October 2015
Recent criticism of IER use (Gould modification)
Not necessary in acute repairs – because tissues not as stretched as in chronic cases (White, 2015)
Not anatomical – calcaneal attachment 10mm anterior to CFL insertion
May restrict full ankle plantarflexion (Behrens, 2013)
White WJ, McCollum GA, Calder JD. Return to sport following acute lateral ligament repair of the ankle in professional athletes. Knee Surg Sports Traumatol Arthrosc 2015
Behrens SB, Drakos M et al. Biomechanical analysis of Brostrom versus Brostrom-Gould lateral ankle instability repair. FAI 2013;34:

15. Lateral Stabilization using Periosteal Flap to reconstruct ATFL & CFL
Rudert et al (1997)
Single or double longitudinal turndown periosteal flaps
ATFL +/- CFL reinforcement or reconstruction
Use of bone tunnels, bone troughs, bone blocks, staples
Kuner EH, 1978; Kuner EH. 1986; Roy-Camille R, 1986; Zwipp H, 1990; Wirth CJ, 1991; Sjolin SU, 1991;Rudert M, 1997; Mabit C, 1998; Rosenbaum D, 1999.

16. “Pants-over-Vest” Periosteal Flap
Described in revision procedures (Kuhn, 2006)
More recently in primary procedures (Molloy, 2014)
Divide capsule/ATFL at fibula edge
Mobilise periosteum with sharp dissection
Kuhn MA, Lippert FG. Revision lateral ankle reconstruction. Foot Ankle Int Feb;27(2):77-81.
Molloy Ap, Ajis A, Kazi H. The modified Broström-Gould procedure – early results using a newly described surgical technique. Foot Ankle Surg 2014;20(3):

17. Broström Augmentation with Autograft or Allograft
Broström-Evans:
Autograft of split Peroneus Brevis to augment Broström repair
“Workhorse repair” for general patient population (Girard, Anderson, Davis, 1999)
Patients with hypermobility (Ng and Das De, 2007)
Girard P, Anderson RB, Davis WH, Isear JA, Kiebzak GM. Clinical evaluation of the modified Brostrom-Evans procedure to restore ankle stability. Foot Ankle Int Apr;20(4):
Ng ZD, Das De S. Modified Brostrom-Evans-Gould technique for recurrent lateral ankle ligament instability. J Orthop Surg (Hong Kong) Dec;15(3):

18. Broström Augmentation with Autograft or Allograft
Autograft or allograft tendon
e.g. semitendinosus, gracilis
Can be used to augment ATFL +/- CFL

19. Broström Augmentation with Autograft or Allograft
Gracilis autograft or allograft tendon
Description of technique without results

20. Strength of Broström repairs
Load to failure
(in Newtons)
Semitendinosus allograft
Waldrop NE 3rd, Wijdicks CA, Jansson KS, LaPrade RF, Clanton TO. Anatomic suture anchor versus the Broström technique for anterior talofibular ligament repair: a biomechanical comparison. Am J Sports Med Nov;40(11): doi: / Epub 2012 Sep 7.
Viens NA, Wijdicks CA, Campbell KJ, LaPrade RF, Clanton TO. Anterior Talofibular Ligament Ruptures, Part 1: Biomechanical Comparison of the Augmented Broström Repair Techniques with the intact Anterior Talofibular Ligament. AJSM 2014;42(2):
Clanton TO, Viens NA, Campbell KJ, Laprade RF, Wijdicks CA. Anterior talofibular ligament ruptures, part 2: biomechanical comparison of anterior talofibular ligament reconstruction using semitendinosus allografts with the intact ligament. AJSM 2014:42(2):
Waldrop NE. AJSM. 2012;40(11): ; Viens NA et al. AJSM. 2014:42(2); ; Clanton TO et al. AJSM. 2014:42(2):

21. Beware the Ossicle ! Why ? Tips: Be aware ! Size of Ossicle:
Ossicle needs removing as part of repair
Part of capsule and lateral collateral ligament complex attached
When removed leaves defect at lateral malleolar tip
Increases gap that needs to be bridged
Tips:
Be aware !
Take care to enucleate ossicle to leave as thick a layer of
tissue as possible to help repair
Mobilise tissues fully to help reduce tension on repair
Size of Ossicle:
<1cm: Excise + Broström
>1cm: Fusion of ossicle and/or Ligament Reconstruction (Guillo, 2013)

22. Post-stabilisation dissatisfaction and intra-articular pathology
13-35% of patients post-reconstruction report pain and recurrent instability
Rechtine GR, McCarroll JR et al (1982)
Eyring EJ, Guthrie WD (1986)
Karlsson J, Bergsten T et al (1988)
Sammarco GJ, DiRaimondo CV (1988)
Taga I, Shino K et al (1993)
Persistent intra-articular pathology has been cited as the cause of many of these continuing symptoms

23. Associated Ankle Joint Problems in patients with Lateral Ligament Instability
Taga et al.
Am J Sports Med 1993;21:
Kibler et al.
Clin Sports Med 1998;15:
Arthroscopy on consecutive series of 46 ankles before Broström stabilization
Intraarticular problems identified in 83%
Anterolateral soft tissue impingement (26%)
Tibial or talar spurs (26%)
Meniscoid lesions (15%)
Chondral injury (13%)
Loose body (13%)
31 athletes undergoing lateral ligament reconstruction
Chondral lesion in:
29% of acutely
95% of chronically injured ankles

24. Associated Ankle Joint Problems in patients with Lateral Ligament Instability
Ribbans. October 2015
Choi et al.
AJSM 2008;36:
97% of patients with CAI (n=65)
had intra-articular lesions
81% soft-tissue impingement
38% lateral malleolus ossicles
29% syndesmosis widening (>2mm of lateral fibula displacement with probe placed in syndesmosis)
23% OCD of talus
Acute Syndesmotic injury
Choi WJ, Lee JW, Han SH, et al. Chronic lateral ankle instability. The effect of intra-articular lesions on clinical outcome. AJSM 2008;36:
Most commonly associated with poor outcomes

25. Arthroscopic Broström Techniques
Thermal Shrinkage
Arthroscopic Broström
1st reported by Oloff in 2000
Number of positive papers since (Berlet, 2002; Hyer, 2004; Maiotti, 2005; deVries, 2008)
“All-inside” technique for tightening ATFL & IER
Technique first described by Kashuk (1997)
Many subsequent papers published on it
Now dedicated commercial kits specifically for the procedure
Oloff LM, Bocko AP, Fanton G. Arthroscopic monopolar radiofrequency thermal stabilization for chronic lateral ankle instability: a preliminary report on 10 cases. J Foot Ankle Surg. 2000; 39(3):
Berlet GC, Saar WE, Ryan A, Lee TH. Thermal-assisted capsular modification for functional ankle instability. Foot Ankle Clin Sep; 7(3):
Hyer CF, Vancourt R. Arthroscopic repair of lateral ankle instability by using the thermal-assisted capsular shift procedure: a review of 4 cases. J Foot Ankle Surg Mar-Apr;43(2):104-9.
Maiotti M, Massoni C, Tarantino U. The use of arthroscopic thermal shrinkage to treat chronic lateral ankle instability in young athletes. Arthroscopy. 2005; 21(6):
de Vries JS, Krips R, Blankevoort L, Fievez AW, van Dijk CN. Arthroscopic capsular shrinkage for chronic ankle instability with thermal radiofrequency: prospective multicenter trial. Orthopedics Jul;31(7):655.
Kashuk KB, Carbonell JA, Blum JA. Arthroscopic stabilization of the ankle. Clin Podiatr Med Surg.1997;14:

26. Arthroscopic Broström Techniques
Ribbans. October 2015
Arthroscopic Broström Techniques
Capsule and ATFL +/- CFL alone (“classic Broström”)
Broström + Gould (IER)
InternalBrace
Autograft/Allograft
Giza E, Whitlow SR, et al. Biomechanical Analysis of an arthroscopic Broström Ankle ligament repair and a suture anchor-augmented repair. FAI 2015;36(7):
Biomechanical strength of arthroscopic Broström repairs = average of 154N load (Giza, 2015)

27. Minimally Invasive InternalBrace Augmentation
NO attempt at tightening capsule / ATFL / CFL / IER Reinforcement of both ATFL and CFL 34 females <70kgs 91% satisfactory functional results RTS (jogging) average was 10.2 weeks
WJR Comments:
NO attempt to tighten lax tissues
Relationship of tape to Peroneal tendons
Long-term possibility of tape elongation

28. Strength of Broström repairs
Load to failure
(in Newtons)
Waldrop NE 3rd, Wijdicks CA, Jansson KS, LaPrade RF, Clanton TO. Anatomic suture anchor versus the Broström technique for anterior talofibular ligament repair: a biomechanical comparison. Am J Sports Med Nov;40(11): doi: / Epub 2012 Sep 7.
Viens NA, Wijdicks CA, Campbell KJ, LaPrade RF, Clanton TO. Anterior Talofibular Ligament Ruptures, Part 1: Biomechanical Comparison of the Augmented Broström Repair Techniques with the intact Anterior Talofibular Ligament. AJSM 2014;42(2):
Clanton TO, Viens NA, Campbell KJ, Laprade RF, Wijdicks CA. Anterior talofibular ligament ruptures, part 2: biomechanical comparison of anterior talofibular ligament reconstruction using semitendinosus allografts with the intact ligament. AJSM 2014:42(2):
Waldrop NE. AJSM. 2012;40(11): ; Viens NA et al. AJSM. 2014:42(2); ; Clanton TO et al. AJSM. 2014:42(2):

29. Broström Repair – Augmentation with the Internal Brace
Fibrewire augmentation secured with Biocomposite SwiveLock anchors
Not an excuse for undertaking an Anatomic repair – it augments it!
Differences in technique – usually dependent upon Surgeon preference for Broström repair itself

30. Broström repair Tri-Laminar Repair With elements of
Gould: using free edge of IER
Karlsson: by detaching at origin from fibula
+ periosteal reinforcement
Periosteum / ST
IER
Internal Brace
Fibula
Capsule + Ligament
Curved or vertical approach around distal fibula
Identify/mobilise IER
Sharp dissection of capsule/ligaments
Posteriorly identify Peroneal tendons and CFL
Mobilise periosteum/soft-tissue
Arthrex Anchors /- separate anchor for CFL
+/- InternalBrace
Tri-laminar Repair
Separate 2/0 Ethibond
Proximal
Distal
Tri-Laminar Repair

31. Internal Brace Broström Augmentation – 6/52 post-op

32. Development of Anatomic (Broström) repair – where am I in 2016 ?
Tightening of the restraining tissues on the lateral side of the ankle (and subtalar joint)
Location ?
Detachment at origin and proximal reattachment of ATFL +/- CFL - Broström (1966); Karlsson (1988)
ATFL alone
How many ligaments ?
ATFL + CFL
Fixation ?
Bone Anchors – Paden (1994); Li (2009); Curry (2011)
Synthetic – Internal Brace - Mackay (2012)
Free edge of IER – Gould (1980)
Augmentation ?
Fibula periosteum – Kuner (1986); Zwipp (1990); Sjolin (1991)
Open – mid lateral
Modifications ?

33. Results – Reviewed 1st 20 patients (2.2013-7.2014)
5 male; 15 female
Average age: 31.6 years (17-63)
Follow-up:
13-32 months
Average: 23 months
ALL 15 athletes:
ALL return to running <12 weeks
ALL RTS at same level <26 weeks
19 primary
1 revision
Complications:
1 superficial wound – antibiotics. On holiday in USA.
1 reported re-”sprain” at 6 months (Taekwondo international) – ok with PT
Sports:
15 regular sport
5 not regular sport

34. InternalBrace – Pros and Cons
Advantages
Disadvantages
Biomechanically stronger
Allows quicker rehabilitation
Protects repair
Useful in revision cases and poor tissue quality
Bioabsorbable fixation
Knotless
Flat tape
Biocompatible (?)
Avoids morbidity of harvesting autogenous tissue, e.g. tendons
Cost
Avoid intra-articular (synovitis) or subcutaneous position (skin irritation)
Does it stress-shield autogenous tissue?
Can over-restrain
NOT an excuse for doing a PROPER procedure!

35. FibreTape- collagen ingrowth. Illustrations courtesy of Peter Millett
Repaired cuff with FibreTape
Healed cuff at 4 months

36. Indications for the use of the InternalBrace for Lateral Ligament Instability
For ALL?
High demand athletes with need for expeditious rehabilitation?
Large ossicles and/or poor quality tissue?
Revision cases?

37. Techniques in Foot and Ankle Surgery.
Accepted for publication in 2016
Surgical Technology International 2015;26:

38. Thank YOU

39. Cost of Implants Product Local UK price (1.2016)
Swedish Krona (£1 = 12.2 Krona)
2.4mm Anchors
£104
1268 kr
InternalBrace
£667
8137 kr
Tightrope for Syndesmosis
£230
2806 kr