Bostrom Technique For Reconstruction Of The Anterior Talo-Fibular Ligament

The talocrural joint (ankle) is a joint complex that allows the orientation of the foot in all directions of space, shock absorption, and weight transmission to the support in static and locomotion. To withstand the action of high stresses, the ankle joint must be stable in both joint statics and dynamics. The stability of the ankle is mixed, resulting from the combined action of bone and ligament elements. The geometric conformation of the articular surfaces is mainly responsible for bone stability.

A sprain occurs when the ligaments are partially or completely damaged, following an abnormal movement of this joint. Although ankle sprains are common minor injuries, approximately 25% of those who have an ankle sprain will experience long-term joint pain and instability.

The most common cause of ankle sprain is inversion. If this movement is repeated (tennis, football, basketball) or simply if a patient happens to make several sprains, the ligaments in the lateral area of the ankle (anterior and posterior talofibular and calcaneofibular) can be completely damaged, in which case they must be surgically reconstructed.

Chronic lateral instability of the ankle can cause pain and dysfunction in amateur or professional athletes or active people. Untreated, chronic instability can lead to late sequelae, such as arthritis and ankle deformity. 

Surgical management of chronic ankle instability can be performed with a Brostr reconstruction, a well-accepted technique with good to excellent results. However, recurrent instability is reported after acute re-injury and chronic repair of the anterior talofibular ligament (ATFL) at rates of 16%. In addition, rehabilitation after Brostr's reconstruction is long-lasting, which can be a nuisance for professional athletes, workers, or active people.

Surgical technique

Our medical team begins the procedure with a standard arthroscopy of the ankle to identify and treat intra-articular pathology. This is done quickly under spinal anesthesia (spinal anesthesia).

In the second surgical time, a linear incision centered on the anterior talofibular ligament is performed. Dissect the subcutaneous tissue and excise the existing fat at this level, up to the lower extensor retinaculum and the anterior lateral ligament complex. The tendons of the long and short peroneal muscles are highlighted, as anatomical landmarks. Peroneal tendon pathologies, such as partial ruptures, are visualized and addressed directly in this procedure, through tendon reconstruction.  

The anterior talofibular ligament (ATFL) is identified and removed along with the surrounding periosteum and the ankle joint capsule from its insertion on the anterior edge of the distal fibula along with the inferior extensor retinaculum, to visualize the lateral edge of the talus and the ligament insertion at this level. 

Next, after highlighting the turtleneck, make a channel with a 2.7 mm drill and insert a suture anchor with 3.5 mm SwiveLock biocomposite (Arthrex), which has at its top fixed a Fiber Tape suture very thick). Normal anchor bolts, as well as FiberTape, are passed through the ATFL sleeve and the extensor retinaculum.

In the anterolateral part of the peroneal malleolus are then fixed 2 anchors BiosutureTak of 2.4 mm (Arthrex), so that between them we can fix a third anchor of 4.75 mm SwiveLock. Wire The needles of the BiosutureTak anchors are then used to pass the sutures through the ATLF ligament and the extensor retinaculum, at a distance of 10-15mm from each other.  

Then, the ankle should then be reduced to a neutral position. The sutures from each BiosutureTak suture anchor are connected thus completing the Brostr technique.

Subsequently, a 3.5mm hole is made in the fibula, and FiberTape is fixed with a 4.75mm SviweLock anchor, thus being made in the Internal Brace to superstabilize the ligament reconstruction. The anchor is fixed with the ankle held in a neutral position. This step is essential to avoid a significant limitation of joint movement and over-stress of the ankle joint.

The technique can also be performed arthroscopically but has a lower surgical accuracy.

At home

Although recovery after this operation is much faster than a classic intervention, it will still take a few weeks for you to fully recover the operated joint. You should expect pain and discomfort for at least a week postoperatively. You can use a special ice pack, which will reduce the pain and inflammation. You must be careful not to lean on the operated area in the first weeks because the pain and discomfort can worsen. You can take a bath, but without wetting the bandage and incisions. The threads are suppressed at 14 days postoperatively.

At 3 months postoperatively, an MRI is necessary to see how the tendon suture heals. Driving is allowed after 8 weeks and hard physical work after 10 weeks.

Physical therapy plays a very important role in the rehabilitation program, and the exercises must be followed by a physical therapist until the end of the recovery period.

It is very important to follow the recovery program strictly and seriously for the surgery to be a success. Our medical team works on average with the patient after this intervention, 12-16 weeks until complete recovery of the operated area.