Ankle ligament instability is a frequent source of ankle pain in adolescents and adults. Although most patients will respond to a nonsurgical plan of strengthening exercises, proprioceptive training, and bracing, some patients will continue to have pain and recurrent sprains that require surgery.

Surgical techniques are evolving, and high success rates have been reported with both ligament repair-type procedures and tendon graft ligament reconstruction. Improvements in soft-tissue suture anchors and arthroscopic equipment has led to the development of techniques that enable ankle stabilization to be performed through limited incisions or through entirely arthroscopic procedures.

Jorge I. Acevedo, MD, and Peter G. Mangone, MD, are among those on the forefront of this technology in the United States. "Over the last 30 years, patients with knee and shoulder instability have come to expect minimally invasive, arthroscopic surgical techniques. We are now experiencing the same technique evolutionary path within the world of orthopaedic foot and ankle surgery," said Dr. Acevedo.

The arthroscopic technique is a modification of the techniques described by Broström in the 1960s, in which the lateral anterior talofibular ligament (ATFL) is folded (reefed) and secured surgically to restore stability. Broström's initial technique was to simply reef the ligaments "pants over vest" style; many surgeons, however, use the techniques popularized by Karlson.

The Karlson technique involves making a trough in the anterior distal fibula and suturing the incompetent ligaments directly into the resultant cancellous surface. In the technique developed by Drs. Acevedo and Mangone, the trough is created with an arthroscopic burr, and suture anchors and specialized suture-passing cannulas are used to grasp the ATFL and lateral joint capsule subcutaneously so that the supporting structures can be reefed directly into the anterior fibula.

A biomechanical study of the technique has been conducted on cadaver models by Eric Giza, MD, and colleagues. They compared the arthroscopic technique to an open repair and found equivalent stiffness and strength.

Clinical results have also been promising. Drs. Acevedo and Mangone published preliminary results of the technique in 2015. In a series of 93 patients with a mean follow-up of 28 months, scores on the Karlsson–Peterson functional scale improved significantly—from a preoperative mean of 28.3 to a postoperative mean of 90.2. Two patients had continued instability, and five had postoperative neuritis. These results compare favorably with published results using traditional open techniques.

What you need to know
In a recent conversation with Drs. Acevedo and Mangone, I asked about their treatment protocol. My questions and their responses follow.

• Who is the ideal patient for this procedure?
  All patients who are appropriate candidates for an open Broström procedure may be considered for the arthroscopic ligament repair. Patients who have had an unsuccessful course of physical therapy and who continue to have recurrent ankle instability symptoms are candidates.
• Should any patients not be considered as candidates for the arthroscopic technique?
  Patients who should be considered for allograft reconstruction techniques are not candidates for an arthroscopic ligament repair. These include patients who have morbid obesity, collagen disorders, and hyperelastic syndromes, those who have undergone revision surgery, and some high-demand patients.
• What workup or preoperative testing is necessary?
  All patients should undergo an appropriate course of conservative management, including physical therapy and bracing or taping prior to surgical intervention. An MRI should be considered preoperatively to assess for occult pathology such as osteochondral lesions and peroneal tendon pathology. Stress radiography can be helpful, although it is not mandatory if physical findings are pronounced.
• Is the technique appropriate for participants in collision sports such as football or rugby?
  Arthroscopic ligament repair can be used in carefully chosen patients who participate in collision sports. This procedure has been successfully performed on several Division I soccer and football players.
• What advantage does the arthroscopic procedure have compared to a traditional open procedure done through a formal incision?
  Compared to current open techniques, the arthroscopic technique avoids problems such as fluid extravasation that obscures normal tissue planes, increased soft-tissue swelling and pain after larger open incisions, and increased intraoperative time due to patient repositioning. Our results equal or surpass published reports using traditional open Broström–Gould reconstruction. Patients report decreased pain and swelling with the arthroscopic technique compared to traditional open surgery.
• What is the postoperative protocol?
  No weight bearing is allowed for the first 2 weeks. In weeks 3 and 4, patients are allowed weight bearing as tolerated, using a boot walker, and range of motion exercises (avoiding inversion) are started. Transition to a lace-up-style gauntlet ankle brace is initiated at 4 to 6 weeks, as is formal physical therapy emphasizing peroneal muscle strengthening. The ankle brace should be worn for up to 12 weeks, and should be used for any sports and high-impact activities for at least 6 months after surgery.

Summary
Arthroscopic lateral ligament reconstructive techniques are a rapidly evolving area in the field of ankle arthroscopy. "The goal of these newer arthroscopic procedures is to obtain equivalent or better results than traditional open techniques," said Dr. Mangone. Several studies published during the past 5 years on lateral ankle ligament reconstruction show good results for different arthroscopic techniques. Although further study is needed, the arthroscopic procedure appears to be an acceptable alternative to traditional open techniques in carefully selected patients.

Vincent J. Sammarco, MD, is in private practice with Reconstructive Orthopaedics and Sports Medicine Inc., in Cincinnati, Ohio, and a member of the AAOS Now editorial board.

Bottom Line

• Treating ankle ligament instability arthroscopically is an evolving area of orthopaedic foot and ankle surgery.
• Studies have found equivalent functional and clinical results for arthroscopic treatment compared to open treatment.
• Patients should undergo a course of conservative, nonsurgical treatment—including physical therapy—prior to considering surgery for ankle instability.
• Patients with morbid obesity, collagen disorders, and hyperelastic syndromes; those who have undergone revision surgery; and some high-demand patients may require allograft reconstruction and should not be considered for arthroscopic repair.

References:

1. Acevedo JI, Mangone PG: Arthroscopic lateral ankle ligament reconstruction. Tech Foot Ankle Surg 2011;10(3):111–116.
2. Acevedo JI, Mangone P: Arthroscopic Brostrӧm technique. Foot Ankle Int 2015;36(4):465–473.
3. Acevedo JI, Mangone P: Ankle instability and arthroscopic lateral ligament repair. Foot Ankle Clin 2015;20(1):59–69.
4. Giza E, Shin EC, Wong SE, et al: Arthroscopic suture anchor repair of the lateral ligament ankle complex: A cadaveric study. Am J Sports Med 2013;41(11):2567–2572.
5. Giza E, Whitlow SR, Williams BT, et al: Biomechanical analysis of an arthroscopic Broström ankle ligament repair and a suture anchor-augmented repair. Foot Ankle Int 2015;36(7):836–841.