Arthroscopic-Assisted Versus All-Arthroscopic Ankle Stabilization Ankle Techniques

The modified Broström Gould (MBG) procedure has long been considered the gold standard for the operative treatment of chronic lateral ankle instability, despite relying on chronically attenuated and often “wispy” native tissues for the repair.

Interestingly, recent research has suggested that the addition of the inferior extensor retinaculum (IER), or “Gould modification” as it is more commonly known, may not actually impart any significant benefit to the repair; other authors have also pointed out that the superolateral band of IER required for the modification may only present in less than half of all operative cases.

Given the different materials and techniques used when performing the MBG, the previous points highlight even further the inherent variability that one must be cognizant of when discussing the MBG and trying to analyze outcomes based on the best available research.

Regardless, given the attenuated lateral soft tissues, many postoperative protocols include a period of non-weightbearing in a posterior splint, followed by immobilization in a weightbearing cast, and finally, progressive rehabilitation. This is of in-course despite evidence that such a protocol may be detrimental to both the joint and the ligaments themselves.

So, where may we be headed?

Over the last decade, “outside in” and “in-side out” MBG techniques using arthroscopy have continued to gain popularity. Proponents cite the natural progression ligament repair techniques in orthopedics, which has gravitated over time towards arthroscopic repair. Critics, on the other hand, cite a steeper learning curve and a reported complication rate for the arthro-Broström (“outside in” technique) as high as 29% as reasons to approach the repair open.

Although the presence of intra-articular pathology has been clearly established, the question remains: Is there a safer way to perform lateral ankle stabilization arthroscopically?

Okay, now the study

Over the last decade, “outside in” and “in-side out” MBG techniques using arthroscopy have continued to gain popularity. Proponents cite the natural progression ligament repair techniques in orthopedics, which has gravitated over time towards arthroscopic repair. Critics, on the other hand, cite a steeper learning curve and a reported complication rate for the arthro-Broström (“outside in” technique) as high as 29% as reasons to approach the repair open.

Thirty-nine patients were arthroscopically treated for ankle instability by Guelfi et al. using either the “outside in” or artho-Broström group and the “inside out” or “all inside” group. The mean follow up for both groups exceeded a year, and functional outcomes using the American Orthopaedic Foot & Ankle Society hindfoot score and visual analog pain scale (VAS), range of motion (ROM) and complications were assessed.

Overall, both techniques provided improvements in the observed parameters with excellent clinical results. However, the “outside in,” or artho-Broström group, had a higher overall complication rate than the “inside out” or “all inside” groups. The two most common complications were painful restriction of ankle plantarflexion (exceeding 10 degrees) and neuritis of the superficial peroneal nerve.

Ready to try either technique?

Maybe not. But at this point you won’t be the first, and as the saying goes, you don’t want to be the last one, either.