SLR - February 2021 - Lant Abernathy

All-Inside Arthroscopic Modified Broström Technique to Repair Anterior Talofibular Ligament Provides a Similar Outcome Compared With Open Broström-Gould Procedure

Reference: Zhou YF, Zhang ZZ, Zhang HZ, Li WP, Shen HY, Song B. All-Inside Arthroscopic Modified Broström Technique to Repair Anterior Talofibular Ligament Provides a Similar Outcome Compared With Open Broström-Gould Procedure. Arthroscopy. 2020 Sep 7:S0749-8063(20)30724-6. doi: 10.1016/j.arthro.2020.08.030. Epub ahead of print. PMID: 32911005.

Level of Evidence: III, Retrospective Comparative Case Series

Scientific Literature Review

Reviewed By: Lant Abernathy, DPM
Residency Program: Inova Fairfax Medical Campus – Falls Church, VA

Podiatric Relevance: Paradigm shifts in the foot and ankle community have advocated for more minimally invasive approaches as viable alternatives for surgical interventions. For the lateral ankle instability patients, conventional Broström-Gould (BG) modification with the inferior extensor retinaculum (IER) reinforcement techniques have been compared to arthroscopically assisted all-inside (AI) techniques in repair of the anterior talofibular ligament (ATFL). However, there is little data on this augmentation of the IER within the AI category, which demonstrated the need for thorough debridement within the subcutaneous tissue in order to anatomically incorporate the IER into the AI repair. Therefore, a comparison of functional, clinical, and subjective outcomes between the conventional open BG to a new AI technique including IER was obtained. 

Methods: Thirty-six and 31 patients were separated into the BG and AI groups respectively. Clinical (positive anterior drawer sign (ADT) and MRI evidence of ATFL tear were inclusion criteria. Functional outcomes measured pre/ post-operative AOFAS, VAS, Sefton, and the Karlsson-Peter scores. ADT data collected at six months and two years post-op. Grades of classification of ADT were categorized into 0-3 with < 5, 5-10, 10-15, and > 15 respectively. Surgical technique for the AI group included arthroscopic debridement of the fibula footprint of the ATFL with an accessory anterolateral portal to secure 1-2 suture anchors within the fibula and secondly allowed for a PDS suture to pass through the portal and secure the ATFL and IER and anchor it to the fibula. The same was performed in the BG except through a traditional curvilinear incision over the lateral malleolus. The number of suture anchors placed was based off of activity level of the patient using the Tenger score. Post-operative protocol was identical between the two groups. 

Results: Subjective functional outcome scores showed statistically significant improvement pre to post op in the AI and BG groups. ADT objective data displayed the BG group 34 and 2 and the AI group as 30 and one in grades one and two respectively. No significance was shown between the two groups. Tenger scores improved significantly in both group’s pre and post- operative, but no significance between the two groups as well as if there 1-2 suture anchors placed was observed. Operative time favored the AI group. 

Conclusions: Outcomes between the open vs the AI groups were ultimately equivocal.  Minimally invasive approaches offer similar functional outcome without the risk of possible complications associated with open procedures. It must also be recognized that AI technique does have its shortcomings, the biggest being surgeon experience/familiarity with the procedure. Popularization with ankle instability repair through arthroscopic AI procedures, provides a challenge to the foot and ankle surgeon to learn and adapt in order to add a potentially valuable skill to. 

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