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Surgical Treatment of Pediatric Ankle Instability: Outcomes of a Modified Brostrom Procedure

February 10, 2018

Contributors: James David Bomar; Amanda Nichole Davis-Juarez, BS; Morgan Dennis, BS; Eric William Edmonds, MD; Andrew Tennant Pennock, MD; Kathleen Dolores Rickert, MD; Kathleen Dolores Rickert, MD

2018 AWARD WINNER Background and Purpose: Ankle sprains account for 30% of sports-related injuries in children. The primary treatment option for these injuries is nonsurgical management, such as bracing or physical therapy. Ligamentous repair is warranted in children with chronic ankle instability. The modified Broström technique of direct anatomic repair, particularly in combination with the Gould technique of imbrication of the extensor retinaculum, has been supported with biomechanical and clinical data. We perform a modification of this technique that incorporates the distal fibular periosteum in the construct. This video describes the outcomes of our modified Broström technique for the management of chronic lateral ankle instability in immature athletes, with an emphasis on 6 weeks of postoperative casting. Methods: Forty-six children underwent the modified Broström technique over a period of 7 years. Exclusion criteria included lack of outcome scores and patients with inherent ligamentous instability because of connective tissue disorders or congenital malformations. All the patients underwent a modified Broström procedure between August 2009 and June 2016. A chart review was conducted to collect demographic, surgical, and clinical data, and a telephone survey was conducted to collect Marx Activity Rating Scale scores, University of California–Los Angeles Activity scores, and Foot and Ankle Outcomes Scores. Results: Eighteen children met the inclusion criteria, and the mean time to clinical postoperative follow-up was 25.3 months. Ten of the eighteen patients underwent concomitant ankle arthroscopy, one of whom (10%) was found to have an associated chondral injury intraoperatively. The mean Marx Activity Rating Scale score was 13.2 ± 4.0. The mean University of California–Los Angeles Activity score was 8.2 ± 2.2. The mean total Foot and Ankle Outcomes Score was 83.2 ± 18.1 (pain, 84.1 ± 17.6; symptoms 80.8 ± 23.2; activities of daily living, 91.5 ± 14.7; sport, 74.7 ± 28.2; quality of life, 60.4 ± 28.4). Optimal results (defined as a score of >75% in three or more categories) were achieved in 72.2% of the patients (13 of 18). No postoperative complications were reported in this cohort. Five of the patients (27.8%) reported recurrent instability and sprains. One of the patients (5.6%) underwent revision surgery for ankle instability within 6 months of the primary procedure. Conclusions: Lateral ankle sprains are frequent injuries that rarely require surgical management; however, the modified Broström technique that incorporates the distal fibular periosteum results in good clinical outcomes and improved stability. A longer duration of casting may not result in improved functional scores; however, it appears to result in improved Marx Activity Rating Scale scores compared with a shorter duration of casting (2 weeks).