AANA Lab Course 908-Foot and Ankle Arthroscopy (APEx)-Open Brostrom_ Still the Gold Standard

Open Brostrom_ Still the Gold Standard_ Richard Ferkel, M.D

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This document reviews the treatment of lateral ankle instability (LAI), emphasizing the open Brostrom-Gould procedure as the gold standard for surgical repair. LAI involves mechanical instability where ankle motion exceeds normal physiological limits, often leading to chronic problems and osteoarthritis. Predisposing factors include proprioceptive dysfunction, peroneal tendon issues, varus deformities, and fibular malposition.<br /><br />Historically, Brostrom (1966) first described anatomic ligament repair by tightening torn ligaments to restore stability, with Gould (1980) augmenting this repair using the extensor retinaculum to reinforce stability, limit inversion, and correct subtalar instability. The open Brostrom-Gould procedure involves arthroscopic evaluation to identify and treat intra-articular lesions (common in 90%+ cases), followed by an open ligament repair using a key incision and multiple sutures for a secure "pants-over-vest" capsular repair.<br /><br />Postoperative treatment typically includes non-weight bearing with a controlled ankle motion boot and physical therapy. Outcomes show high success rates (91-100%) with improved function and stability. Arthroscopic Brostrom ("ArthroBrostrom") is technically demanding, more expensive, and may inadequately tighten the calcaneofibular ligament (CFL), risking less effective stabilization and nerve injury. Because CFL integrity significantly affects ankle stability and biomechanics, its proper repair is crucial.<br /><br />For patients with poor ligament tissue, generalized laxity, or failed prior repairs, augmentation with a semitendinosus (ST) allograft is recommended. This method involves reconstructing the ATFL and CFL using hamstring tendon grafts secured with interference screws, showing promising outcomes in young, athletic populations.<br /><br />In summary, open Brostrom-Gould remains the preferred surgical approach for LAI, balancing anatomical restoration and joint motion preservation. Arthroscopic techniques may suit lower demand patients with milder instability. Use of ST allograft augmentation should be reserved for select cases requiring additional support. Maintaining maximum ankle motion without overtightening the repair is critical for optimal function.

Keywords

lateral ankle instability

Brostrom-Gould procedure

ankle ligament repair

open Brostrom-Gould

arthroscopic Brostrom

calcaneofibular ligament

semitendinosus allograft

ankle biomechanics

postoperative rehabilitation

ankle stability