Brostrom-Gould Procedure 27698

synonyms:Brostom-Gould procudure, lateral ankle ligament reconstruction, ankle instability repair, 

Brostrom-Gould CPT

• 27698

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-Gould 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

• 100% good to excellent results for ankle arthroscopy with modified Brostrom-Gould procedure. 95% had associated intra-articular pathology. (Ferkel RD, Foot Ankle Int 2007;28:24).
• 83%-90% satisfactory functional results (Karlsson J, AJSM 1997;25:48).

Brostrom-Gould Review References

Colville MR, JAAOS 1998;6:368