SLR - May 2016 - Sham Persaud

Title: Efficacy of the Modified Broström Procedure for Adolescent Patients With Chronic Lateral Ankle Instability

Reference: Kocher MS, Fabricant PD, Nasreddine AY, Stenquist N, Kramer DE, Lee JT. Efficacy of the Modified Broström Procedure for Adolescent Patients With Chronic Lateral Ankle Instability. J Pediatr Orthop. 2015 Dec 8.

Scientific Literature Review

Reviewed By: Sham Persaud, DPM
Residency Program: Western Pennsylvania Foot and Ankle Institute

Podiatric Relevance: Lateral ankle sprains are very common, representing up to 30 percent of sports-related injuries in both adolescents and adults. During ankle sprains, injuries impact structures including but not limited to the anterior talofibular ligament (ATFL) and less commonly the calcaneofibular ligament (CFL). Injury to these structures can lead to gross ankle instability, deformity and acceleration of degenerative joint disease of the ankle and subtalar joint. Surgical treatment is reserved for injuries that fail non-operative treatment with recurrent instability. Anatomic repair using the modified Broström technique has been shown to be effective in the adult population. However, there is minimal research supporting the procedure use in the pediatric population. Therefore, this study was designed in order to evaluate the effectiveness of the modified Broström technique in the pediatric and adolescent population for chronic lateral ankle instability.

Methods: Thirty-one patients over an eight-year period were included in the current study. Patients with congenital deformity and underlying connective tissue disease were excluded. All patients were treated with a modified Broström technique in which the ATFL was repaired anatomically using suture technique. Twenty-four of the thirty-one patients underwent arthroscopy for intra-articular pathology. Demographic, surgical, and clinical data were collected and outcome scores were obtained, including the Marx activity scale, University of California, Los Angeles (UCLA) activity score, and modified American Orthopedic Foot and Ankle Society (AOFAS) score.

Results: Overall, most patients did very well with the procedure with only 3 complications in total. One patient had persistent pain and subtalar laxity with ankle dorsiflexion. Two other patients experienced wound complications four weeks post-operatively. Both patients healed without incident after debridement and a course of antibiotic therapy. There were no other complications. Average clinical scores were very positive within the patient population. The mean Marx activity score was 9.9±4.7, mean UCLA score was 9.3±1.3, and mean modified AOFAS score was 83.8±11.7. Good-to-excellent results, according to AOFAS, were achieved in 22 of 31 of patients. There were no significant differences between arthroscopy and non-arthroscopy groups. Likewise, there were no differences in any of the clinical outcome scores between males and females.

Conclusions: Traditionally lateral ankle sprains are very common injuries which do well with conservative treatment. However, chronic instability may occur despite appropriate treatment and rehabilitation leading to the need for surgical correction. Surgical correction with direct anatomic repair of the ATFL and CFL utilizing the modified Broström technique for pediatric patients appears to be a viable option according to this article. Pediatric patients not only seem to tolerate the procedure well with minimal complications, they are also able to return to the activities they like to participate in. This paper would guide my therapy in the future as an option to treat acute and chronic ankle instability in adolescent and pediatric patients in the future. 

Educational Opportunities