Point-Counterpoint: Is The Open Broström More Effective Than The Arthroscopic Broström Procedure?

Yes.

As these authors assert, the open Broström-Gould procedure continues to be the gold standard for lateral ankle injuries, offering low complication rates and good visualization of the anterior talofibular ligament for a stronger repair.

By Travis Langan, DPM, AACFAS, and Christopher F. Hyer, DPM, MS, FACFAS

Ankle injuries are an extremely common pathology presenting to the foot and ankle specialist. The incidence of ankle sprains is reportedly between two and seven per 1,000 people, and ankle sprains account for approximately 30 percent of all sports-related injuries.^1-3 Of all sprains, 85 percent involve the lateral ankle.^4,5

Physicians can often successfully treat ankle sprains with non-operative management but sprains can lead to chronic ankle instability, which will require operative intervention. The lateral ankle ligaments, including the anterior talofibular ligament, can become chronically degenerated or torn. A reported 5 to 20 percent of lateral ankle injuries become chronic and require surgical stabilization.^5-8 One should consider operative intervention when a patient has failed conservative treatments for six or more months, or is unable to return to pre-injury activity level after six months. Also consider surgery for acute lateral ankle ligament injuries in a high-level athlete.

Broström originally described his lateral ankle ligament repair in 1966 and Gould proposed his modification in 1980 to reinforce the anterior talofibular ligament repair.^9,10 The Broström-Gould has become the gold standard primary treatment for repairing the anterior talofibular ligament. The Broström procedure consists of an anatomic repair and tightening of the anterior talofibular ligament, which involves incising the ligament and suturing it over itself in a “pants over vest” fashion.

Following repair of the anterior talofibular ligament, reinforce the ligament with the Gould modification by advancing the inferior extensor retinaculum over the anterior talofibular ligament and suturing it into the anterior distal fibula. The procedure has remained essentially the same with some improvements as ligament augmentation techniques have improved. If the native tissue is damaged beyond anatomic repair, there are now many different ways to augment the repair including suture anchors, interference screws, FiberWire tape (Arthrex) and allograft/autograft ligament materials.

Many times, surgeons combine the Broström-Gould procedure with arthroscopic ankle debridement to treat any concomitant synovitis or lesions within the ankle joint. There has been a recent trend in orthopedics toward minimally invasive surgery (MIS). Surgeons can perform the Broström-Gould procedure arthroscopically through an “all inside” technique. However, we feel the open technique continues to have good clinical outcomes, good patient satisfaction and minimal complications.

A Closer Look At The Literature On The Open Broström Procedure

The Broström procedure with the Gould modification procedure has been the gold standard since its popularization and a recent literature review shows that the Broström-Gould procedure remains the standard for reconstructing the lateral ankle ligaments. A meta-analysis of 13 studies in 2018 showed the open technique provides a high patient satisfaction rate of 91.7 percent.⁶ Return to sport activities averaged 4.7 months and the mean return to work was 38.5 days. The meta-analysis also noted an average American Orthopaedic Foot and Ankle Society (AOFAS) score of 90.34. The overall complication rate was 7.92 percent. Complications were minor and most commonly were superficial wound complications (1.98 percent) and sensory disturbances (1.78 percent). Compare this to a 15.27 percent complication rate for the arthroscopic procedure in this study.⁶

So and colleagues reviewed 11 studies of the Brostrom-Gould procedure for lateral ankle ligament repair and showed only a 5.6 percent complication rate and a 1.2 percent revision rate with overconstraint being the most common reason for revision.¹¹  

One argument for the use of the arthroscopic Broström is a faster return to activity. However, D’Hooghe and coworkers compared return to sport times in open versus arthroscopic procedures, and showed the open procedure had a return to sport time of almost one month quicker (2.85 months for open versus 3.79 months for arthroscopic).¹² Matsui and colleagues also showed no significant difference in the time to return to sport when they compared open versus arthroscopic procedures.¹³

Key Insights On Advantages Of The Open Procedure

The clear advantage to performing the open technique is direct visualization of the anatomy and the ability to identify and avoid any high risk structures. Direct visualization of the anterior talofibular ligament allows for a more controlled and accurate repair. One can also accurately identify the inferior extensor retinaculum for proper execution of the Gould modification through an open procedure. The ability to visualize and evaluate other important lateral ankle structures is a key strength to the open procedure.

Associated peroneal tendon pathology is reportedly 25 percent with lateral ankle instability.¹⁴ One can easily visualize peroneal tendons and repair them if necessary during an open procedure through the same incisional approach. Surgeons can also visualize and evaluate the calcaneofibular ligament. Up to 78 percent of lateral ankle instability has associated subtalar joint instability as well.¹⁵ The calcaneofibular ligament is damaged in approximately 15 percent of lateral ankle pathology and one can easily address this in an open procedure.¹⁴ One can evaluate the severity of the damage to the lateral ankle anatomy during an open procedure. Magnetic resonance imaging (MRI) can tend to overestimate or underestimate the damage to lateral ankle ligaments.^16,17 Direct evaluation of the anatomy allows for the surgeon to determine the need for augmentation of the native structures intraoperatively.

The move toward minimally invasive surgery requires a higher level of skills and training. Minimally invasive surgery also poses risks that may not be associated with their open counterpart. The arthroscopic Broström-Gould procedure poses a clear risk to important anatomic structures in the area. Drakos and coworkers performed a cadaveric study showing a high risk of entrapment of an extensor tendon, peroneus tertius or the superficial peroneal nerve.¹⁸ Studies show a complication rate up to 40 percent in the arthroscopic Broström-Gould procedure.¹⁹ In addition, the arthroscopic technique has higher costs due to the surgical equipment required.⁶

In Conclusion

Even after 50 years, the open Broström-Gould procedure continues to have great success with a low rate of complications. One can combine the procedure with ankle arthroscopy to treat intra-articular injuries. However, performing ligament repair with a traditional open approach allows for better visualization and repair of other associated injuries of the lateral ankle complex.

Dr. Langan practices at the Orthopedic Foot and Ankle Center of Columbus in Westerville, Ohio.

Dr. Hyer practices at the Orthopedic Foot and Ankle Center of Columbus in Westerville, Ohio. He is a Fellow of the American College of Foot and Ankle Surgeons. Dr. Hyer is board-certified in foot surgery and reconstructive ankle and hindfoot surgery by the American Board of Foot and Ankle Surgery.

References

1.    Guillo S, Bauer T, Lee JW, Takao M, Kong SW, Stone JW, Pearce CJ. Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy. Orthoped Traumatol Surg Res. 2013; 99(8):S411–S419.
2.    Ferran NA, Maffulli N. Epidemiology of sprains of the lateral ankle ligament complex. Foot Ankle Clin. 2006; 11(3):659–662.
3.    DiGiovanni CW, Brodsky A.). Current concepts: lateral ankle instability. Foot Ankle Int. 2006; 27(10):854–866.
4.    Hølmer P, Søndergaard L, Konradsen L, Nielsen PT, Jørgensen LN. Epidemiology of sprains in the lateral ankle and foot. Foot Ankle Int. 1994; 15(2):72–74.
5.    Garrick JG. Epidemiology of foot and ankle injuries. Foot Ankle Sport Exerc. 1987; 23(1):1-7.
6.    Guelfi M, Zamperetti M, Pantalone A, Usuelli FG, Salini V, Oliva XM. Open and arthroscopic lateral ligament repair for treatment of chronic ankle instability: a systematic review. Foot Ankle Surg. 2018; 24(1):11–18.
7.    DiGiovanni BF, Partal G, Baumhauer JF. Acute ankle injury and chronic lateral instability in the athlete. Clin Sport Med. 2004; 23(1):1–19.
8.    Chan KW, Ding BC, Mroczek KJ. Acute and chronic lateral ankle instability in the athlete. Bull NYU Hosp Joint Dis. 2011; 69(1):17.
9.    Brostrom L. Treatment and prognosis in recent ligament ruptures. Acta Chir Scand. 1966; 132(5):537-550.
10.    Gould N, Seligson D, Gassman J. Early and late repair of lateral ligament of the ankle. Foot Ankle. 1980; 1(2):84-89.
11.    So E, Preston N, Holmes T. Intermediate-to long-term longevity and incidence of revision of the modified Broström-Gould procedure for lateral ankle ligament repair: a systematic review. J Foot Ankle Surg. 2017; 56(5):1076-1080.
12.    D’Hooghe P, Axibal DP, Fuld RS, Sutphin BS, Hunt KJ. Return to play following arthroscopic vs. open treatment of lateral ankle instability in recreational/athletic. Clin Res Foot Ankle. 2018; 6(1):265.
13.    Matsui K, Takao M, Miyamoto W, Matsushita T. Early recovery after arthroscopic repair compared to open repair of the anterior talofibular ligament for lateral instability of the ankle. Arch Orthoped Trauma Surg. 2016; 136(1):93-100.
14.    DiGiovanni BF, Fraga CJ, Cohen BE, Shereff MJ. Associated injuries found in chronic lateral ankle instability. Foot Ankle Int. 2000; 21(10):809-815.
15.    Hertel J, Denegar CR, Monroe MM, Stokes WL. Talocrural and subtalar joint instability after lateral ankle sprain. Med Sci Sports Exerc. 1999; 31(11):1501-1508.
16.    Park HJ, Cha SD, Kim HS, Chung ST, Park NH, Yoo JH, Oh SM. Reliability of MRI findings of peroneal tendinopathy in patients with lateral chronic ankle instability. Clin Orthoped Surg. 2010; 2(4):237-243.
17.    O’Neill PJ, Van Aman SE, Guyton GP. Is MRI adequate to detect lesions in patients with ankle instability? Clin Orthop Rel Res. 2010; 468(4):1115-1119.
18.    Drakos M, Behrens SB, Mulcahey MK, Paller D, Hoffman E, DiGiovanni CW. Proximity of arthroscopic ankle stabilization procedures to surrounding structures: an anatomic study. Arthroscopy. 2013; 29(6):1089-1094.
19.    Wang J, Hua Y, Chen S, Li H, Zhang J, Li Y. Arthroscopic repair of lateral ankle ligament complex by suture anchor. Arthroscopy. 2014; 30(6):766-773.

No.

These authors argue that for lateral ankle stabilization, the arthroscopic Broström provides outcomes that are comparable to the open technique with improved wound healing and a faster return to activity.

By Ruth Moen, DPM, AACFAS, and Shane Hollawell, DPM, FACFAS

Lateral ankle stabilization procedures have high success rates in restoring ankle stability and function. However, without an arthroscopic evaluation and debridement of the ankle joint, up to 20 percent of patients may continue to have symptoms after surgery.¹

Isolated chondral injuries or impingement conditions are not always apparent with preoperative magnetic resonance imaging (MRI). Komenda and Ferkel showed that 96 percent of ankles had intra-articular pathology when patients had arthroscopy in conjunction with lateral ankle stabilization procedures.²

Evidence-based literature clearly indicates the benefits of arthroscopy when addressing patients with chronic lateral ankle pain and instability. Direct visualization of the articular cartilage and the ankle joint will allow surgeons to address the etiology of pain more completely and allow for greater resolution of symptoms as opposed to relying entirely on lateral ligament reconstruction to resolve all ankle symptoms.

Surgeons commonly use the modified Broström procedure to resolve chronic lateral ankle instability and this is currently considered the standard surgical procedure for an unresolved sprain. A better understanding of pathology and intra-articular abnormalities, in addition to the expansion of arthroscopic methods, has increased the indications for arthroscopic intervention. Surgeons with arthroscopy skills can perform the all-inside arthroscopic Broström technique. The arthroscopic approach to lateral ankle stabilization has the potential to provide outcomes similar to the traditional open approach with improved wound healing and quicker return to activity.

What The Literature Reveals About The Arthroscopic Broström

The move to minimally invasive procedures is becoming popular across many aspects of orthopedics and surgery. In general, this has led to the development of “arthroscopic assisted” and “all inside” modified Broström techniques. There is evidence-based literature to support the use of the arthroscopic Broström procedure. There are multiple studies that show the arthroscopic procedure results are at least equally favorable as the traditional open procedure for lateral ankle instability.^3,4 Postoperative anterior drawer and talar tilt test results are comparable to test results of the open procedure.^3,4

Furthermore, biomechanical testing has shown equivalent strength and stiffness between arthroscopic lateral ankle stabilization techniques and the traditional open Broström-Gould technique using match-paired cadavers.⁵ Postoperative American Orthopaedic Foot and Ankle Society (AOFAS), Visual Analogue Scale (VAS), and Karlsson scores are also similar between the two approaches.⁶ A recent systematic review shows that the arthroscopic Broström procedure results in a postoperative AOFAS score of 92.48 and a Karlsson score of 90.2.⁷ The mean patient satisfaction score was 96.4.

The arthroscopic technique also provides long-lasting results. Nery and colleagues published the longest-term data on outcomes, reporting on 38 patients with an average follow-up of 9.8 years.⁸ The authors’ technique involved one anchor for anterior talofibular ligament repair. The study noted excellent stability and function with 87 percent of patients returning to pre-injury level athletics.  

Arthroscopic procedures have the potential to shorten operative times and allow for quicker return to activity based on limited soft tissue disruption. Matsui and coworkers noted an operation time that was 14 minutes quicker and a significantly lower VAS score three days after surgery with arthroscopic lateral ankle repair in comparison to the open traditional technique.⁹ Karlsson and colleagues found that athletes with earlier mobilization of the ankle joint after anatomic lateral ankle stabilization returned to sporting activities quicker and had increased strength with plantarflexion in comparison with those who had prolonged immobilization.¹⁰ The return to daily activity was also almost two weeks shorter in the arthroscopic group. Rigby and Cottom showed a quicker time to protected weightbearing in their arthroscopic group at 12 days in comparison to 22 days for the open technique.¹¹ In their postoperative protocol, the authors note they allow arthroscopic patients to return to normal shoe gear at postoperative day 28.   

A Guide To Performing The Procedure

Prior to the start of the procedure, draw the major lateral anatomic landmarks, including the distal fibula, the course of the peroneal tendons, the superficial peroneal nerve and the borders of the inferior extensor retinaculum. The arthroscopic lateral ankle stabilization procedure begins with ankle arthroscopy through anteromedial and anterolateral portals. A systematic evaluation of the ankle joint allows for the recognition of any existing intra-articular conditions that one can address appropriately. The surgeon would subsequently perform debridement of synovitis, capsulitis, impingement bands and/or osteochondral lesions in or around the ankle joint.

During the lateral ankle stabilization portion of the procedure, use the anteromedial portal as the viewing portal. Use the anterolateral portal for arthroscopic exposure of the anterior distal fibula for anchor placement at the origin of the anterior talofibular ligament. One can repair the anterior talofibular ligament anatomically and reinforce it with the superior slip of the inferior extensor retinaculum. Some protocols include a second suture anchor in the distal fibula for repair of the calcaneofibular ligament. This extraarticular ligament is not repaired under direct visualization. Tension the ligament repair under arthroscopic guidance and make a small percutaneous incision to tie the suture. When employing this method, one should have a strong understanding of topographic anatomy and adhere to established safe zones in order to reduce the risk of neurovascular injury.¹²

Why An Arthroscopic Broström Is Preferable

The arthroscopic lateral ankle stabilization technique can help minimize difficulties one may encounter with traditional open ligament reconstruction by minimizing soft tissue dissection. Ankle arthroscopy and subsequent open ligament repair can be complicated by fluid extravasation, which can make normal tissue planes ambiguous. Larger open incisions are potentially associated with increased soft tissue swelling and pain. The arthroscopic approach decreases the level of soft tissue disruption with subsequent lower levels of tissue plane interruption and an effective decrease in scar tissue deposition. Improved cosmesis with the arthroscopic technique is appealing to some patients.

A critical evaluation of a change to a surgical approach must be beneficial to the patient in order to create a paradigm shift from the gold standard of lateral ankle repair. When comparing the arthroscopic lateral ankle stabilization to the typical open technique, there is a quicker return to pre-injury activity and potential for less scarring at a very mobile joint. The arthroscopic approach allows for earlier mobilization of the ankle joint with less concern for incision healing and potential sequelae associated with motion across larger incision sites. The arthroscopic technique has a reported decrease in wound complications in comparison to the standard open method and allows for a quicker return to activity and sports. In spite of an initial learning curve, the arthroscopic technique can ultimately decrease operative time when the surgeon masters the technique.

In Conclusion

In the absence of the desire for an extra-articular exploration, typically peroneal tendon evaluation, the minimally invasive arthroscopic lateral ankle stabilization technique is very attractive option for chronic lateral ankle instability and has clear evidence-based benefits. The arthroscopic approach can provide similar outcomes to the traditional open approach with improved cosmesis and a quicker return to activity. Patient selection is paramount to obtaining good outcomes. However, a high body mass index and collagen deficiency disorders are relative contraindications to the arthroscopic ankle stabilization technique.

Dr. Moen is a Foot and Ankle Fellow at the Orthopaedic Institute of Central New Jersey in Manasquan, N.J. She is an Associate of the American College of Foot and Ankle Surgeons.

Dr. Hollawell is the Fellowship Director at the Orthopaedic Institute of Central New Jersey in Manasquan, N.J. He is a Fellow of the American College of Foot and Ankle Surgeons. Dr. Hollawell is board-certified in reconstructive rearfoot and ankle surgery, and foot surgery.

References
1.    Eyring DJ, Guthrie WD. A surgical approach to the problem of severe lateral instability at the ankle. Clin Orthop Relat Res. 1986;206:185-191.
2.    Komenda GA, Ferkel RD. Arthroscopic findings associated with the unstable ankle. Foot Ankle Int. 1999;20(11):708-713.
3.    Drakos MC, Behrens SB, Paller D, Murphy C, DiGiovanni CW. Biomechanical comparison of an open vs arthroscopic approach for lateral ankle instability. Foot Ankle Int. 2014;35(8):809-815.
4.    Yeo ED, Lee KT, Sung IH, Lee SG, Lee YK. Comparison of all-inside arthroscopic and open techniques for the modified Broström procedure for ankle instability. Foot Ankle Int. 2016;37(10):1037-1045.
5.    Giza E, Whitlow SR, Williams BT, Acevedo JI, Mangone PG, Haytmanek CT, Curry EE, Turnbull TL, LaPrade RF, Wijdicks CA, Clanton TO. Biomechanical analysis of an arthroscopic Broström ankle ligament repair and a suture anchor-augmented repair. Foot Ankle Int. 2015;36(7):836-841.
6.    Rigby RB, Cottom JM. A comparison of the “All-Inside” arthroscopic Broström procedure with the traditional open modified Broström-Gould technique: A review of 62 patients. Foot Ankle Surg. 2018; epub Feb. 9.
7.    Guelfi M, Zamperetti M, Pantalone A, Usuelli FG, Salini V, Oliva XM. Open and arthroscopic lateral ligament repair for treatment of chronic ankle instability: a systematic review. Foot Ankle Surg. 2018;24(1):11-18.
8.    Nery C, Raduan F, Del Buono A, et al. Arthroscopic-assisted Broström-Gould for chronic ankle instability: a long-term follow up. Am J Sports Med. 2011;39(11):2381-2388.
9.    Matsui K, Takao M, Miyamoto W, Matsushita T. Early recovery after arthroscopic repair compared to open repair of the anterior talofibular ligament for lateral instability of the ankle. Archives Ortho Trauma Surg. 2016;136(1):93-100.
10.    Karlsson J, Bergsten T, Lansinger O, et al. Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg Am. 1988;70(1):581-588.
11.    Cottom JM, Rigby RB. The “All-Inside” arthroscopic Broström procedure: a prospective study of 40 consecutive patients. J Foot Ankle Surg. 2013;52(5):568-574.
12.    Aceveda JI, Ortiz C, Golano P, Nery C. ArthroBrostrom lateral ankle stabilization technique: an anatomical study. Am J Sports Med. 2015;43(10):2564-2571.