How does a revision Broström‑Gould ankle ligament repair with internal‑brace augmentation alter postoperative management compared with a primary repair?

Revision Broström-Gould with Internal Brace: Postoperative Management Differences

Revision ankle ligament surgery fundamentally alters the postoperative experience by introducing higher failure risk, prolonged healing, and more cautious rehabilitation compared to primary repair—however, internal brace augmentation in revision cases may partially mitigate these concerns by providing mechanical protection during the vulnerable healing phase.

Key Differences in Revision Surgery Context

Tissue Quality and Healing Considerations

• Revision procedures involve compromised tissue quality from prior surgery, including scar tissue formation and potentially attenuated ligamentous structures that heal more slowly than virgin tissue 1
• Poor bone stock from previous anchor placement can compromise initial fixation strength, a fundamental cause of early loosening in revision scenarios 2, 3
• The inflammatory response from prior surgery creates a less favorable biological environment for healing, similar to particle-induced osteolysis seen in other orthopedic revisions 2, 3

Mechanical Stability Concerns

• Inadequate initial fixation is more likely in revision cases due to compromised bone quality at previous anchor sites, predisposing to micromotion and early failure 3
• Malalignment from the index procedure may have progressed to instability, requiring correction during revision surgery 2
• The risk of re-rupture is substantially higher in revision scenarios without augmentation—one study showed 3 re-ruptures requiring further revision in non-augmented repairs versus zero with internal brace augmentation 4

How Internal Brace Augmentation Modifies Revision Recovery

Accelerated Rehabilitation Protocol

• Internal brace augmentation allows earlier weight-bearing (4.14 weeks versus 6 weeks in non-augmented repairs, p<0.01), which is particularly advantageous in revision cases where prolonged immobilization risks stiffness 4
• Patients can begin range of motion exercises earlier due to the mechanical protection provided by the suture tape construct 5, 6
• Return to sport occurs significantly faster with internal brace augmentation (mean 84.1 days in primary repairs), though revision cases may require additional time 5

Immobilization Differences

• Significantly less time in plaster cast with internal brace augmentation (4.14 weeks versus 6 weeks, p<0.01), reducing the risk of arthrofibrosis and joint stiffness that complicates revision scenarios 4
• Transition from splint to walking boot occurs at 6 weeks with progressive weight-bearing per physical therapy protocol 6, 7
• Initial non-weight-bearing period in short leg cast or boot remains standard for the first 6 weeks regardless of augmentation 7

Functional Outcomes in Revision Context

Superior Results with Internal Brace

• Manchester-Oxford Foot Questionnaire scores are significantly better with internal brace augmentation (mean overall raw score 10.9 versus 33.6, p<0.016), suggesting improved outcomes even in challenging revision scenarios 4
• Pain scores are significantly lower (4.86 versus 10.9, p<0.042) with internal brace augmentation 4
• Social interaction and standing/walking subscales show significant improvement (2 versus 7.5, p<0.023 and 4 versus 15.2, p<0.012 respectively) 4

Complication Rates

• Zero postoperative complications occurred in the internal brace group versus seven complications in the non-augmented group (p<0.057), a critical consideration in revision surgery where complication risk is inherently elevated 4
• No re-ruptures requiring further revision occurred with internal brace augmentation versus three in the non-augmented group (p<0.53), addressing the primary concern in revision scenarios 4
• Return to preinjury activity level is achievable in 90.2% of internal brace patients versus 83.7% in non-augmented repairs, with significantly faster return time (12.1 versus 20.3 weeks, p<0.001) 8

Critical Clinical Pitfalls in Revision Cases

Avoid Overtightening

• Overtightening of the ATFL during revision repair increases postoperative stiffness, a particular concern when dealing with previously scarred tissue 7
• Ankle should be positioned in slight eversion and dorsiflexion during closure to prevent excessive tension 7

Bone Quality Assessment

• Periscrew lucency >2mm on postoperative radiographs indicates significant loosening and warrants close monitoring in revision cases 3
• Poor bone quality from previous anchor sites requires careful preoperative planning for alternative fixation points 3

Monitoring for Failure

• Serial radiographs are more helpful than single examinations for detecting subtle loosening in revision scenarios 2
• Bone scintigraphy shows 20% false-positive rate at 1 year and 12.5% at 2 years in asymptomatic patients, complicating interpretation after revision surgery 2, 3

Specific Rehabilitation Timeline for Revision with Internal Brace

Weeks 0-6

• Non-weight-bearing in short leg cast or boot with foot in slight eversion and dorsiflexion 6, 7
• No active range of motion during this initial healing phase 6

Weeks 6-12

• Transition to walking boot with progressive weight-bearing per physical therapy protocol 6, 7
• Begin gentle range of motion exercises protected by the internal brace construct 6
• Expect full weight-bearing by 8-10 weeks in uncomplicated revision cases 4

Weeks 12-16

• Advance to functional rehabilitation including proprioceptive training 6
• Sport-specific exercises can begin once strength and stability milestones are achieved 5, 6

Return to Sport

• Average return to sport at 12.1 weeks with internal brace augmentation, though revision cases may require additional 2-4 weeks 8
• 86.4% of patients return to normal or near-normal function on single-leg hop testing 5