Ankle ligament reconstruction (Broström) surgery

When surgery is considered

For background on the condition, see chronic ankle instability. Rehabilitation and bracing are the foundation of treatment, and surgery is generally considered when:

• the ankle continues to give way despite months of supervised rehabilitation
• instability is severe, or keeps you from work or sport
• imaging or arthroscopy shows another problem that needs treatment along with the ligaments. Examples are a cartilage injury (see ankle cartilage repair), a damaged peroneal tendon (see peroneal tendon surgery), or soft-tissue impingement^[3,4,6]

The main types of operation

• Anatomic repair (Broström or Broström–Gould). The stretched-out or torn ligaments are shortened and reattached to the bone in their original positions. The repair is often reinforced with a nearby band of tissue (the Gould modification). It restores the normal anatomy and keeps normal motion. A review of studies with at least ten years of follow-up found better function and less later arthritis after anatomic repair than after older, non-anatomic operations.^[2,1]
• Reconstruction with a tendon graft. When the ligaments are of poor quality or the ankle has been unstable for a long time, the ligaments can be rebuilt using a tendon graft. Non-anatomic operations that re-route a tendon (tenodesis) are used less often; in one trial they were associated with more nerve injuries than anatomic reconstruction.^[7]
• Arthroscopic repair. Some surgeons perform the repair through small incisions with the help of a camera. A meta-analysis of six comparative studies found slightly higher functional scores and lower pain scores after arthroscopic repair than after open repair. Stability testing and overall complications did not differ, and wound complications were less likely with the arthroscopic approach.^[5]
• Treating other problems. Ankle arthroscopy allows the surgeon to look inside the joint at the same time and to treat problems such as impingement or a cartilage injury. See ankle arthroscopy.

Comparisons between techniques are limited: randomized trials are few and small, and the differences among anatomic repair techniques were small.^[8]

Recovery

Recovery follows your operation and the quality of the tissue. A typical plan is a period of protection in a splint, boot or brace. Then comes a graduated return to weight-bearing and motion, followed by physical therapy to restore strength and balance. Timing varies between surgeons and protocols. A systematic review found that starting movement early (within three weeks) was associated with better functional scores. It was also associated with slightly more laxity on testing and a higher complication rate than starting later. The authors call for more randomized studies to establish the optimal timetable.^[9] The rehabilitation guideline for the ankle emphasizes supervised exercise for the recovery of strength, balance and function.^[10,11]

Return to sport depends on how you recover, and generally takes months. See recovery after foot and ankle surgery.

Risks

Risks include infection, wound-healing problems, stiffness and recurrent instability. Nearby nerves, particularly the small sensory nerves around the outside of the ankle, can be injured or irritated. As with any surgery, there is also a risk of blood clots.^[7,5,12] The chances are influenced by how loose the ankle was before surgery, the quality of the tissue, and whether other problems were present.

Questions to ask before deciding

• Have I done enough rehabilitation, and is there anything else worth trying?
• Do I need imaging or arthroscopy before surgery to check for other problems?
• Which repair do you recommend for my ankle, and would it be done open or arthroscopically?
• When can I walk on the ankle, drive, and return to work and sport?

When to seek care