Brostrom Procedure

Original Editor - Kalyani Yajnanarayan

Top Contributors - Kristen Holeman, Kalyani Yajnanarayan, Alexandra Stead and Vidya Acharya  

Introduction

The Broström procedure is the surgical reconstruction of the ligaments of the lateral ankle, specifically the anterior talofibular ligament (ATFL) as well as the calcaneofibular ligament (CFL) when applicable. The aim of the procedure is to restore normal ankle stability for patients with chronic lateral ankle instability (CLAI) that have been unsuccessful with conservative treatments including physiotherapy and immobilisation. There are many variations to the traditional open Broström procedure developed in 1966 involving the anatomical repair of the ATFL. This has since been modified by Gould in 1980 and Karlsson in 1989, as well as arthroscopic repairs being performed as early as 1987. The Broström procedure and its modifications are widely regarded as the gold standard for surgical management of CLAI.

Relevant Anatomy

Lateral ankle instability is a common lower extremity injury sustained by individuals in the general population, and for individuals that fail conservative management, significant functional limitations can occur. Three ligaments provide support to the lateral structure of the ankle:

• Anterior talofibular ligament (ATFL) – Originates on the anterior aspect of the lateral malleolus and commonly composed of two bands. It limits anterior translation of the talus as well as excessive plantarflexion and inversion of the talocrural joint.
• Calcaneofibular ligament (CFL) – Spans both the talocrural joint and the subtalar joint running in an anterior to posterior direction. It limits talar inversion and injury commonly occurs with the ATFL.
• Posterior talofibular ligament (PTFL) – Originates along the medial distal fibular and runs horizontally to attach on the posterolateral talus. It limits dorsiflexion and is only identified in 5-10% of ankle sprains.  The PTFL rarely requires surgical management and is not included as part of the Broström technique.

The inferior extensor retinaculum (IER) is a Y-shaped band that lies anterior to the talocrural joint and attaches to the upper surface of the calcaneus running lateral to medial. It is comprised of two layers forming a strong loop around the Peroneus tertius and extensor digitorum tendons, acting as a pulley system for stabilisation.

Conservative Management and Surgical Indications

Rehabilitative Approach

Before surgical intervention is considered, patients with CLAI typically undergo a comprehensive course of conservative management aimed at addressing the mechanical and functional impairments contributing to persistent instability.

The 2021 APTA Clinical Practice Guideline for Lateral Ankle Ligament Sprains recommends an impairment-based rehabilitation program that may include:

• External support (taping, bracing, or orthoses) when indicated, in conjunction with therapeutic exercise
• Progressive therapeutic exercise to restore ankle and lower extremity strength
• Proprioceptive, neuromuscular, and dynamic balance training
• Restoration of ankle mobility through stretching, joint mobilisation, manipulation, and weight-bearing/non-weight-bearing mobilisation with movement
• Functional training, including running, jumping, landing, agility, and change-of-direction activities as appropriate
• Dry needling when clinically indicated
• Activity modification, patient education, and a progressive home exercise program

Despite a comprehensive rehabilitation program, a subset of patients can continue to experience recurrent ankle sprains, persistent instability, pain, and functional limitations. Surgical stabilisation may be considered for these individuals after failure of appropriate conservative management.

For an in-depth review of the pathophysiology, clinical presentation, examination, and nonsurgical management of chronic ankle instability (CAI), refer to Chronic Ankle Instability.

Indications for Surgical Consultation

Surgical treatment may be indicated for patients with CLAI who continue to experience symptoms despite an appropriate course of conservative management. CLAI is commonly characterised by recurrent ankle sprain or “giving way” for more than 12 months following a previous injury. Associated symptoms may include pain, persistent swelling, perceived ankle joint instability, recurrent injury and decreased functional capacity.

According to consensus recommendations from the Chinese Society of Sports Medicine, surgical intervention should be considered in patients who meet the following criteria:

1. Persistent symptoms of CLAI despite 3-6 months of appropriate nonsurgical management.
2. Physical examination findings consistent with lateral ligament insufficiency, including tenderness over the lateral ligament or positive anterior drawer test or talar tilt test.
3. Imaging studies, such as stress radiography or magnetic resonance imaging (MRI), confirming chronic lateral ligament injury.

Although these recommendations provide a useful framework for surgical decision-making, the decision to proceed with surgery should also consider patient-specific factors, including activity level, occupational demands, degree of mechanical instability, generalised ligamentous laxity, associated intra-articular pathology, and patient goals.

Surgical Procedures

Open Broström Procedure

The anatomical repair of the lateral ligaments of the ankle was developed by Broström in 1966 and is now widely known as the Broström Procedure. This technique and its modifications have been the gold standard surgical intervention for CLAI.

With the classic Open Broström Repair, an incision is made over the lateral malleolus to identify the torn ATFL and perform a repair to this ligament, as well as the possible CFL. If there is an injury to the fibularis tendons as well, the incision is then moved more posteriorly in order to provide better access to the tendons for repair. Care is taken to protect the fibularis tendons, sural nerve, lesser saphenous vein, and the branches of the superficial peroneal nerves. This technique performs direct suture repair to the pulled ends of the injured ligaments, typically the ATFL and occasionally the CFL.

Modified Broström-Gould Procedure

In 1980, Gould built off of the original Broström procedure by including a reinforcement involving IER in lateral ankle ligament repair, which differs from the original procedure by now utilising a two-step technique. The initial stages of the procedure are carried out similarly to the original Open Brostrom, however, after the ATFL, and CFL if applicable, are surgically repaired, the IER is then attached to the lateral malleolus advancing over the ATFL repair and sutured to the remaining periosteal flap as reinforcement to the newly repaired ligaments. With fixation of the IER, the repair of the ATFL is augmented, and it is thought to provide a stronger lateral stabiliser to the ankle. Recent modifications have included more than one suture anchor to reattach the ligament as well as the IER to the original origin of the ligament on the lateral malleolus. During the repairs of the ligament(s), it is important that the ankle is held in neutral dorsiflexion with eversion to minimise stress to the repaired ligaments.

Recent anatomical studies confirmed that the IER is a weak band of tissue that will probably not add significant strength to ankle stability. Postoperative follow-up indicated that clinical and radiographic outcomes were not significantly different based on whether or not IER reinforcement was performed. Therefore, isolated ligament reconstruction without IER may be sufficient to restore ankle stability.

Arthroscopic Repair

The traditional Broström procedure involves an open anatomical repair of the lateral ankle ligaments using suture anchors. With advances in surgical techniques, arthroscopic and minimally invasive approaches have emerged as alternatives to the open procedure. In particular, the arthroscopic Broström-Gould repair has gained popularity because it offers the potential benefits of reduced surgical trauma and less postoperative pain compared to the open approach.

Arthroscopic Broström Procedure

In 1987, Hawkins first described an arthroscopic approach to the Broström procedure, representing a significant advancement in the surgical management of chronic lateral ankle instability. During the procedure, the arthroscope is introduced through an anteromedial viewing portal located just lateral to the tibialis anterior tendon. An anterolateral working portal is then established anterior to the lateral aspect of the talar trochlea, allowing visualisation of the ATFL and, when indicated, the CFL. The injured ligament(s) are subsequently repaired anatomically using suture anchors and sutures.

The introduction of arthroscopic techniques has enabled surgeons to evaluate and address concomitant intra-articular pathology during ligament repair. Compared with the traditional open Broström procedure, arthroscopic repair may be associated with less postoperative pain and an earlier return to sport. However, current evidence demonstrates comparable clinical outcomes and complication rates between the two approaches.

Complications

Overall complication rates following the Broström procedure can range depending on the technique with some evidence displaying a rate of 7.9-10.1% for open procedures and 9.3-15.3% for arthroscopic procedures. Complications following the surgical treatment of CLAI are relatively low, but can present specific problems, including nerve damage, poor wound healing or infection, pain, fibular fracture, deep vein thrombosis (DVT), and the possibility of recurrent instability. Recurrent instability or failure of surgery can range from 0-32% of cases due to poor definition of instability, with a more appropriate approximation being closer to 11%.

Infection

Current systematic reviews report low overall complication rates for both open and arthroscopic techniques. Although wound infections appear to occur more frequently after open repair than arthroscopic repair, the absolute incidence remains low at a rate of 0.98%, and both procedures demonstrate comparable overall safety profiles. More common than infection is superficial wound issues with a complication rate of 1.98-3.75%.

Nerve Damage

Due to the cutaneous nerves surrounding the tissue near the incision site, neurologic complications can occur following Broström repair. The superficial peroneal nerve (SPN) is the nerve most commonly at risk during Broström repair because of its proximity to the lateral incision and arthroscopic portals. Nerve injuries are uncommon, occurring in approximately 4.6% of arthroscopic repairs and 2.8% of open repairs, with most presenting as transient numbness or paraesthesia rather than permanent neurologic deficits. Cadaveric studies have shown that the intermediate branch of the superficial peroneal nerve may lie within 15.9 mm of the anterolateral portal, emphasising the need for careful portal placement during arthroscopic procedures.

Post-operative Management

Currently, there is no universally accepted postoperative rehabilitation protocol for CLAI. Although numerous studies have evaluated different rehabilitation strategies, variations in study design and rehabilitation protocols limit the ability to establish evidence-based recommendations for optimal postoperative management.

Rehabilitation Precautions

Postoperative rehabilitation should protect the repaired lateral ligaments while progressively restoring ankle mobility, strength, and function. During the early postoperative period, excessive inversion stress, forced plantarflexion with inversion, premature weight-bearing, and aggressive range-of-motion exercises should be avoided to protect the healing repair. Progression should be based on tissue healing, surgeon preference, and objective functional milestones rather than time alone. Evidence suggests that although earlier mobilisation may improve short-term functional outcomes, it is also associated with greater postoperative laxity and wound complications, supporting a cautious, criterion-based rehabilitation approach.

Rehabilitation Phases

Although no universally accepted postoperative rehabilitation protocol exists for chronic lateral ankle instability (CLAI), the clinical practice guideline by Feng et al. provides an evidence-based framework to guide rehabilitation. Progression should be individualised according to tissue healing, surgical technique, surgeon preference, and functional milestones rather than predetermined timelines.

Phase 1: Protection and Symptom Management

Goals

• Protect the surgical repair
• Control pain and oedema
• Protect the incision
• Maintain proximal strength and mobility

Interventions

• Immobilisation in boot/cast per surgeon
• Pain management
• Oedema control (compression, elevation, cryotherapy)
• Non-weight-bearing or weight-bearing per surgeon
• Hip, knee, and core exercises
• Patient education

Phase 2: Progressive Weight-Bearing and Mobility

Goals

• Restore normal gait
• Gradually increase ankle ROM
• Progress weight-bearing
• Begin gentle muscle activation

Interventions

• Progressive weight-bearing
• Gait training
• Active ROM (avoid excessive inversion)
• Gentle strengthening
• Joint mobility as appropriate

Phase 3: Strength and Sensorimotor Control

Goals

• Restore lower extremity strength
• Improve dynamic stability
• Enhance proprioception and balance

Interventions

• Progressive strengthening
• Single-leg balance training
• Neuromuscular re-education
• Functional movement training
• Cardiovascular conditioning

Phase 4: Advanced Strength and Functional Training

Goals

• Restore power and endurance
• Improve agility and movement quality
• Prepare for sport-specific demands

Interventions

• Plyometric progression
• Agility and change-of-direction drills
• Running progression
• Sport-specific training
• Hop and landing mechanics

Phase 5: Return to Sport or High-Level Activity

Goals

• Safe return to unrestricted activity
• Minimise reinjury risk

Criteria

• Full, pain-free ROM
• Normal strength
• Good dynamic balance
• Successful hop and functional testing
• Psychological readiness
• Surgeon clearance

Outcomes and Prognosis

Overall, the Broström procedure and its modifications have demonstrated favourable clinical outcomes, with significant improvements in ankle stability, patient-reported function, and return to sport. A recent systematic review reported that 95% of patients returned to some level of sport, 83% returned to their preinjury level of participation, and 87% returned to competitive sport following surgery. However, return-to-sport outcomes may be influenced by patient-specific factors, including age and body mass index (BMI), with older age and a higher BMI associated with lower rates of return to preinjury sport.

Despite these favourable outcomes, recurrent instability remains a recognised cause of treatment failure. Reports of an overall recurrence rate of approximately 11%, with rates ranging from 0 to 32% is demonstrated across studies. Generalised joint laxity, high-level sports participation, female sex, varus hindfoot alignment, poor ligament quality, and intraoperative syndesmotic widening have been identified as risk factors for recurrent instability following operative treatment.