What are the indications, surgical technique, and postoperative protocol for arthroscopic ArthroBroström (modified Broström‑Gould repair with internal‑brace augmentation) in an adult with chronic lateral ankle instability who has failed at least six weeks of structured non‑operative care?

Arthroscopic ArthroBroström for Chronic Lateral Ankle Instability

For adults with chronic lateral ankle instability who have failed at least 6 weeks of structured non-operative care, arthroscopic modified Broström-Gould repair with internal brace augmentation is an effective surgical option that provides comparable outcomes to open surgery with potential advantages in pain reduction, faster return to sport, and improved cosmesis.

Indications

The primary indication is chronic lateral ankle instability (CLAI) that has not responded to comprehensive exercise-based physiotherapy. Key clinical criteria include:

• Mechanical instability: Documented ligament laxity on anterior drawer and talar tilt testing
• Functional instability: Persistent subjective instability, recurrent sprains, or inability to return to desired activity level
• Failed conservative management: Minimum 6 weeks (ideally 3-6 months) of structured rehabilitation including neuromuscular training, proprioceptive exercises, and bracing 1
• Adequate ligament remnant: The procedure depends on sufficient anterior talofibular ligament (ATFL) tissue quality for repair 2

Important caveat: 60-70% of patients with lateral ankle sprains respond well to non-surgical treatment, so surgery should be reserved for true non-responders 1. Professional athletes may warrant earlier surgical consideration given the high demands on ankle stability 1.

Surgical Technique

The arthroscopic ArthroBroström combines modified Broström repair with internal brace augmentation and addresses intra-articular pathology:

Portal Placement and Diagnostic Arthroscopy

• Standard anteromedial and anterolateral portals
• Critical finding: Intra-articular lesions are present in 93% of CLAI cases, including synovitis/soft tissue impingement (67%), chondral injuries (40%), and anterior osteophytes (40%) 3
• Address these concomitant pathologies arthroscopically before ligament repair

Anchor Placement and Ligament Repair

• Fibular anchor: Place at the anatomic ATFL footprint on the anterior distal fibula
• Talar anchor: Position at the talar ATFL insertion site
• Use knotless anchor technology when possible—one knotless anchor screwed to the fibula can accomplish both ligament repair and tape fixation 2

Internal Brace Augmentation

• Pass suture-tape through the remnant ATFL tissue
• Secure to fibular anchor, then fix to talar anchor
• The internal brace provides immediate mechanical stability while biological healing occurs 2, 4

Gould Modification (Inferior Extensor Retinaculum)

• Critical technical point: Use a semiconstrained freehand tie rather than a knot pusher for the IER augmentation
• Knot pusher technique results in 23% incidence of ankle stiffness with limited plantarflexion 5
• Freehand tying prevents overtightening and maintains full range of motion 5

Postoperative Protocol

Immediate Postoperative Period (0-2 weeks)

• Short-leg splint or boot immobilization
• Non-weightbearing or protected weightbearing as tolerated
• Early ankle pumps and toe range of motion

Early Rehabilitation (2-6 weeks)

• Transition to functional ankle brace
• Progressive weightbearing
• Begin gentle range of motion exercises
• The internal brace augmentation may allow for accelerated rehabilitation compared to traditional repair 4

Advanced Rehabilitation (6-12 weeks)

• Proprioceptive and neuromuscular training—this is essential to prevent recurrence 1, 6
• Progressive strengthening
• Sport-specific training

Return to Sport

• Arthroscopic technique with internal brace shows faster return to sport compared to open procedures (approximately 4 weeks earlier) 7
• Typical timeline: 3-4 months for return to full activity
• Mandatory: Continue ankle bracing during sports for at least 6 months post-surgery 1

Clinical Outcomes

The arthroscopic ArthroBroström demonstrates:

• Functional scores: AOFAS scores improve from approximately 64 preoperatively to 93 postoperatively 3
• Pain: Significantly better VAS scores compared to open surgery 7
• Stability: Comparable anterior drawer and talar tilt correction to open procedures 7
• Satisfaction: 87-91% patient satisfaction rates 8
• Complications: Similar overall complication rates to open surgery (approximately 10-12%) 7, 8

Key Advantages Over Open Surgery

While both techniques show comparable functional outcomes 7:

• Reduced postoperative pain 7
• Earlier return to sport (3-4 weeks faster) 7
• Ability to address intra-articular pathology simultaneously 3
• Improved cosmesis and reduced wound complications 4, 9

Critical Pitfalls to Avoid

1. Overtightening the IER: Use freehand tying technique to prevent plantarflexion stiffness 5
2. Inadequate rehabilitation: Proprioceptive training is non-negotiable—lack of neuromuscular rehabilitation contributes to the 25-40% rate of persistent instability 1, 6
3. Missing concomitant pathology: Always perform thorough diagnostic arthroscopy as 93% have additional intra-articular lesions requiring treatment 3
4. Insufficient ligament tissue: If remnant ATFL is inadequate, consider alternative reconstruction techniques rather than forcing a primary repair 2