Single-Incision Broström-Gould Surgery with Peroneal Debridement and Calcaneal Osteotomy.

Abstract

Background: Broström-Gould surgery is the gold standard operative treatment of chronic lateral ankle instability. In cases of failed nonoperative treatment, the Broström-Gould repair aims to improve lateral ankle stability via anatomic repair and the overlapping of the anterior talofibular ligament (ATFL) and calcaneofibular ligament, with reinforcement of the ATFL by the extensor retinaculum^1-3. Lateral ankle ligament injuries typically present with additional pathologies, including hindfoot varus, peroneal tendon lesions, and tarsal coalition^4,9. Previous studies have hypothesized that treatment of ligamentous injuries with concurrent osteotomy of the calcaneus can correct altered stress loading, aiding in the prevention of future injuries and complications^4,9,10. The presently described technique is a modification of the Broström-Gould technique that allows the addition of a calcaneal osteotomy without additional incisions.

Description: Patients are positioned supine with a foam bump under the torso on the ipsilateral side and bone foam to elevate and pronate the operative foot. The incision begins 4 cm proximal to the tip of the lateral malleolus, posterior to the peroneal tendons, and ends 1 cm proximal to the base of the fifth metatarsal. Subcutaneous tissues are bluntly dissected, and neurovasculature is protected. Tenosynovectomy of the peroneus longus and brevis is performed. During the tenosynovectomy, care must be taken to avoid damaging the sural nerve, which is posterior to the tendon sheath. Hohmann retractors are utilized to better visualize the lateral calcaneus. Calcaneal osteotomy is performed with use of a micro saw for the lateral two-thirds and with use of an osteotome for the medial third. In the example case, a single 7.0-mm cancellous screw was utilized for fixation; however, 2 screws can be utilized to provide greater rotational stability. The ATFL is elevated from the talus and lateral malleolus. The lateral malleolus is freed of periosteum with use of a rongeur. Two 3.5-mm suture anchors (each with 4 needles) with number-0 FiberWire (Arthrex) are inserted through the tip of the lateral malleolus. The suture material is passed through the ATFL and calcaneofibular ligament to tighten the ligaments. The superior extensor retinaculum is advanced over, and sutured to, the ATFL. The incision is closed in layers, and a short leg splint is applied with the foot in slight eversion and dorsiflexion. Patients are transitioned from the splint to a short leg non-weight-bearing cast or boot for 6 weeks. At 6 weeks postoperatively, the patient is transitioned to a walking boot for progressive weight-bearing per a physical therapy protocol.

Alternatives: Nonoperative treatment of chronic ankle instability involves rest and physical therapy with bracing or the use of orthotics. Operative treatments are performed when nonoperative treatment has failed. Alternatives include isolated open Broström-Gould repair, arthroscopic Broström repair, Broström repair augmented with a suture internal brace, a Chrisman-Snook procedure, and allograft repair of the ATFL^1-3,11. Recent focus has been placed on the use of minimally invasive surgical techniques, including those for calcaneal osteotomies. The proposed technique offers advantages compared to minimally invasive calcaneal osteotomies by allowing for debridement of the peroneal tendons.

Rationale: A previous study on single-incision Broström-Gould surgery with calcaneal osteotomy has shown this technique to be safe and effective, without increased risk of postoperative complications^5,6. This approach offers a useful modification to the Broström-Gould procedure by allowing for a simultaneous calcaneal osteotomy without the need for additional incisions. Advantages include decreased risk of incision-site complications and improved cosmesis.

Expected outcomes: The Broström-Gould procedure has been shown to provide excellent patient satisfaction⁷. The goal of this surgery is to stabilize the ankle joint, allowing for improved mobility and decreased pain. On the basis of clinical evidence, modified versions of the Broström-Gould procedure, including a single-incision procedure with calcaneal osteotomy, have no proven clinical inferiority or increased risk of complications^6-8. The addition of a calcaneal osteotomy with a single-incision technique allows for the correction of varus deformities, lowering the risk of future ligamentous injury and slowing the progression of osteoarthritis⁴. Common surgical complications include superficial wound healing complications, sensory abnormalities, persistent ankle pain, and prolonged swelling⁵. Most patients can tolerate weight-bearing beginning at 6 weeks postoperatively, and patients have a high rate of return to activity¹.

Important tips: Avoid overtightening of the ATFL in order to prevent increased postoperative stiffness.Avoid over medialization of the micro saw blade in order to prevent potential overpenetration.Insufficiency of the calcaneofibular ligament can be identified by checking for opening of the posterior facet of the subtalar joint on an oblique view of the ankle as a guide to include calcaneofibular ligament tissue in the repair.

Acronyms and abbreviations: CLAI = chronic lateral ankle instabilitySLCO = sliding lateralizing calcaneal osteotomyAP = anteroposteriorMRI = magnetic resonance imagingATFL = anterior talofibular ligamentCFL = calcaneofibular ligament.