Brostrom: Re Brostrom Repair Is Easy, Reliable and Has Few - - PowerPoint PPT Presentation

Brostrom: Re

Brostrom Repair Is Easy, Reliable and Has Few Complications

The following relations exists

Royalties and stock options – Smith and Nephew, Wolters Kluwer Consulting income – Smith and Nephew, Geistlich, Ossur, Cannuflow Research and educational support – Mitek, Smith & Nephew & Arthrex

Ankle Sprains

40% of all Athletic Injuries 10% of ER Visits One Inver. Injury /10,000/Day

Introduction

Most Patients With Acute Ankle Sprains Heal With Conservative Treatment - RICE, Brace, PT A Small Minority of Patients Will Develop Chronic Lateral Ankle Instability and Require Surgical Stabilization 13% - 35% of Patients Will Continue to Experience Pain After Lateral Ankle Stabilization

Instability

Functional - Motion Beyond Voluntary Control But Not Necessarily Exceeding Physiologic ROM

P.T.

Instability

Mechanical – Motion Beyond Normal Physiologic Limits of Ankle Joint i.e. Increased Anterolateral Laxity

SURGERY

Why Do Some People Have Repetitive Sprains That Lead to Chronic Instability?

Lateral Ankle Sprains: Predisposing Factors

Proprioceptive Dysfunction Peroneal Tendon Tears of Subluxation Varus Tibial Plafond Varus Heel Posteriorly Positioned Fibular

Chronic Instability Surgery

Failure of Conservative Rx Anatomic Repair is Best Open vs. Arthroscopic Non Anatomic Repair – Many Choices

Brostrom-Gould Procedure

Procedure Also Called “Modified Brostrom” Reefing Torn ATFL and CFL Restores Anatomic Stability Gould Modif. Limits Inversion and Helps Correct Subtalar Instability

Arthroscopic Technique

Supine, 2.7 mm 30° and 70° Scope Thigh Holder Look Anterior & Posterior Distracter as Needed

Unstable Ankle – Scope Findings

Ferkel and Komenda – 55 Ankles Treated With Lateral Ankle Stabilization 93% Had Joint Abnormalities

That Included: Synovitis = 39 Loose Body = 12 Ossicles = 14 OLT = 9 (16%)

FAI 20:708, 1999

Unstable Ankle – Scope Findings

Ferkel & Chams 21 Pts Had Brostrom-Gould 95% Had Associated Intraarticular Abnormalities

FAI 28: 24, 2007 Seen at Arthroscopy Seen During Brostrom Synovitis 16 3 Adhesions 10 2 Chondromalac ia 7 1 Ossicles 6 2 Loose Bodies 5 OLT 4 1 Osteophyte 4 1 TOTAL 52 10

Operative Technique

After Arthroscopy, the Patient is Repositioned

Operative Technique

Ankle is reprepped and draped and all new instruments are used

Brostrom – Gould Procedure Surgical Options

Reef Ligaments Leaving Cuff on Fibula Shorten Ligaments Drill Holes into Fibula Suture Anchors Into Fibula

Brostrom Incisions

Brostrom-Gould Procedure

Must Find “Soft Spot” B/N AITFL and ATFL Place Clamp Into This Area Under Lateral Ligaments Peroneal Tendons Are Protected and Ligaments Incised Key

Ligament/Capsule Release

A B C

Pants Over Vest Ligament Repair

Final Closure

Post-op Treatment

NWB SLC for 2 Weeks FWB SLC or CAM Walker for 4 Weeks P.T. Include Pool & Land

BROSTROM Results

Brostrom, 1966 97% Gould, 1980 100% Hamilton, 1993 96% Ferkel, 2000 95% Kelikian, 2000 91% E-G

Chronic Ankle Instability

Choi et al – 65 Ankles Who Had Modified Brostrom Reconstruction Karlsson-Peterson Score: 53 → 85 63/65 (97%) Had Intraarticular Lesions Factors Ass. With Poor Result

Widening Syndesmosis OLT Ossicles

AJSM 36:2167, 2008

Conclusion

Brostrom – Gould - Anatomic Reconstruction is Best Choice for Most Patients In Certain Pts a ST Allograft Brostrom Reconstruction is Indicated, Either Primarily or in Revision Surgery Regardless of the Procedure, Do Not Over Tighten The Repair & “Capture” the Ankle Anatomic Ankle Motion Must Be Maintained As Much As Possible