Brostrom Repair: Procedure, Recovery, Benefits, and Risks for Ankle Instability

What is a Brostrom Repair?

The Brostrom repair is a surgical procedure designed to restore stability to an ankle joint that has become chronically unstable, most commonly due to repeated lateral ankle sprains, by tightening and reattaching the damaged ligaments on the outside of the ankle.

Understanding Ankle Instability

The ankle joint is a complex structure providing both mobility and stability, crucial for activities ranging from walking to high-impact sports. The most common injury to this joint is a lateral ankle sprain, occurring when the foot rolls inward, stretching or tearing the ligaments on the outside of the ankle. While most acute sprains heal with conservative management, approximately 20-30% of individuals develop Chronic Ankle Instability (CAI). CAI is characterized by a persistent feeling of the ankle "giving way" or "rolling," recurrent sprains, pain, and swelling, significantly impacting physical activity and quality of life. This instability often stems from stretched or torn ligaments that have failed to heal properly, leading to laxity in the joint.

What is the Brostrom Repair?

The Brostrom repair, often referred to as the Brostrom-Gould procedure (a common modification), is a surgical technique aimed at restoring the ankle's natural stability by directly repairing and reinforcing the damaged lateral ankle ligaments. It is considered the gold standard for treating chronic lateral ankle instability. Unlike reconstructive procedures that use grafts from other parts of the body, the Brostrom repair utilizes the patient's own stretched or torn ligaments, tightening them and reattaching them to their original anatomical insertion points on the fibula. This approach aims to preserve the native anatomy and biomechanics of the ankle joint.

Anatomical Structures Involved

The Brostrom repair primarily targets the lateral collateral ligaments of the ankle, which are crucial for preventing excessive inversion (inward rolling) of the foot. These include:

• Anterior Talofibular Ligament (ATFL): The most commonly injured ligament in lateral ankle sprains, connecting the fibula to the talus at the front of the ankle. It is the primary restraint to anterior translation of the talus and inversion.
• Calcaneofibular Ligament (CFL): Connects the fibula to the calcaneus (heel bone). This ligament provides stability against inversion, particularly when the ankle is in a neutral or dorsiflexed position.
• Posterior Talofibular Ligament (PTFL): Less commonly injured, connecting the fibula to the talus at the back of the ankle, primarily resisting posterior talar translation.

The procedure focuses on shortening and reinforcing the ATFL and often the CFL, re-establishing their tension and function. In the modified Brostrom-Gould technique, a portion of the inferior extensor retinaculum (a fibrous band that holds tendons in place) is sutured over the repaired ligaments to provide additional strength and support.

Indications for a Brostrom Repair

A Brostrom repair is typically recommended for individuals experiencing chronic lateral ankle instability after exhausting conservative treatment options. Key indications include:

• Persistent Ankle Instability: A recurring sensation of the ankle "giving way" or feeling unstable during daily activities or sports.
• Recurrent Ankle Sprains: Multiple episodes of ankle sprains despite appropriate rehabilitation and bracing.
• Failure of Conservative Treatment: Unsuccessful outcomes from a comprehensive program of physical therapy, bracing, activity modification, and anti-inflammatory medications, typically over 3-6 months.
• Chronic Pain and Swelling: Associated with the instability and mechanical issues within the joint.
• Ligamentous Laxity: Clinical examination and imaging (MRI) confirming significant stretching or tearing of the ATFL and/or CFL.
• Absence of Significant Arthritis: The procedure is less effective if severe ankle arthritis is present, which may require different interventions.

The Surgical Procedure

The Brostrom repair is usually performed under general or regional anesthesia. The steps generally involve:

1. Incision: A small incision (typically 3-5 cm) is made on the lateral (outside) aspect of the ankle, over the fibula.
2. Ligament Exposure: The surgeon carefully identifies the damaged ATFL and CFL.
3. Ligament Tightening and Reattachment: The stretched or torn ligaments are carefully detached from their insertion on the fibula. Small bone anchors are often placed into the fibula, and strong sutures are passed through the ligaments. The ligaments are then pulled taut and reattached to the fibula using these sutures, effectively shortening and tightening them.
4. Augmentation (Modified Brostrom): In the Brostrom-Gould modification, a flap of the inferior extensor retinaculum is mobilized and sutured over the repaired ligaments. This acts as an internal brace, providing additional reinforcement and strength to the repair.
5. Closure: The incision is closed in layers, and a sterile dressing is applied. The ankle is typically immobilized in a splint or cast immediately after surgery.

Benefits of a Brostrom Repair

The Brostrom repair offers several significant advantages for individuals suffering from chronic ankle instability:

• Restored Ankle Stability: The primary benefit is the significant reduction or elimination of the feeling of the ankle "giving way," allowing for greater confidence in movement.
• Pain Reduction: By stabilizing the joint, the procedure often alleviates chronic pain associated with instability and recurrent microtrauma.
• Improved Function and Activity Level: Patients can typically return to their desired level of physical activity, including sports, with a stable and reliable ankle.
• Preservation of Native Anatomy: Unlike some reconstructive procedures, the Brostrom repair uses the patient's own existing ligaments, maintaining the natural biomechanics of the ankle.
• Reduced Risk of Future Injury: A stable ankle is less prone to recurrent sprains and potentially long-term degenerative changes like arthritis.
• High Success Rates: Studies report success rates of 85-95% in restoring stability and function.

Potential Risks and Complications

While generally safe and effective, like any surgical procedure, a Brostrom repair carries potential risks:

• General Surgical Risks:
  • Infection: At the surgical site.
  • Bleeding: Excessive bleeding or hematoma formation.
  • Adverse Reaction to Anesthesia: Allergic reactions or other complications.
  • Deep Vein Thrombosis (DVT): Blood clots in the leg, which can potentially travel to the lungs (pulmonary embolism).
• Specific Ankle Risks:
  • Nerve Damage: The sural nerve, which provides sensation to the side of the foot, runs close to the incision site and can be irritated or, rarely, damaged, leading to numbness or burning sensations.
  • Stiffness: Post-operative immobilization and scar tissue can lead to reduced range of motion.
  • Persistent Pain: While rare, some patients may experience ongoing pain despite a successful repair.
  • Residual Instability: In a small percentage of cases, the repair may not fully restore stability, or the ligaments may stretch out again.
  • Wound Healing Issues: Delayed healing or dehiscence of the incision.
  • Re-injury: Although the goal is prevention, severe trauma can still re-rupture the repaired ligaments.

Post-Operative Recovery and Rehabilitation

Recovery from a Brostrom repair is a structured process requiring commitment to a detailed rehabilitation program. Adherence to physical therapy is crucial for optimal outcomes.

• Immediate Post-Operative (Weeks 0-2):
  • Immobilization: The ankle is typically placed in a non-weight bearing cast or splint immediately after surgery.
  • Pain Management: Prescription pain medication and anti-inflammatories.
  • Elevation and Ice: To reduce swelling.
  • Non-Weight Bearing: Crutches are used to prevent weight from being placed on the operated ankle.
• Early Rehabilitation (Weeks 2-6):
  • Gradual Weight Bearing: Transition to a walking boot, with progressive weight bearing as tolerated.
  • Gentle Range of Motion (ROM): Non-weight bearing ankle circles and dorsiflexion/plantarflexion exercises.
  • Scar Management: Massage to prevent adhesions.
• Intermediate Rehabilitation (Weeks 6-12):
  • Boot Weaning: Gradually transitioning out of the walking boot.
  • Strengthening: Resistance band exercises for all ankle movements, calf raises, isometric exercises.
  • Proprioceptive Training: Balance exercises (e.g., single-leg stance, balance board) to retrain the ankle's stability sensors.
  • Gait Training: Re-education of normal walking patterns.
• Advanced Rehabilitation (Months 3-6+):
  • Sport-Specific Training: Introduction of agility drills, plyometrics, jumping, and cutting motions.
  • Progressive Loading: Increasing the intensity and duration of exercises.
  • Return to Activity: Gradual and supervised return to recreational activities and sports, often requiring continued bracing or taping initially.

Full recovery and return to unrestricted activity can take anywhere from 4 to 9 months, depending on individual healing rates, adherence to rehab, and activity goals.

Long-Term Outlook

The long-term prognosis following a Brostrom repair is excellent for the vast majority of patients. Studies indicate high rates of patient satisfaction and a significant return to pre-injury activity levels, including competitive sports. The procedure effectively reduces the incidence of recurrent ankle sprains and improves overall ankle function. While the repaired ligaments are robust, maintaining ankle strength, flexibility, and proprioception through ongoing exercise is beneficial for long-term joint health and preventing future issues.

When to Consult a Specialist

If you are experiencing persistent ankle instability, frequent ankle sprains, or chronic pain and swelling despite trying conservative treatments, it is crucial to consult with an orthopedic surgeon specializing in foot and ankle conditions. They can accurately diagnose the cause of your symptoms and determine if a Brostrom repair or another intervention is the most appropriate course of action for your specific condition.