Single Incision Brostrom-Gould Repair With Syndesmotic Fixation and Os Trigonum Excision

Ankle sprains are among the most common orthopedic injuries, with many of these resolving with standard non-operative therapy.1,2 The current gold standard treatment for recurrent lateral ankle sprains secondary to chronic ankle instability is the Broström-Gould procedure.3 While this procedure is correlated with excellent outcomes with the majority of patients experiencing a return to normal pre-injury physical function and pain levels, some patients experience refractory pain and instability.1 The continuation of symptoms after surgery may indicate the presence of additional underlying pathologies such as syndesmotic injuries, osteochondral lesions, posterior impingement, and peroneal tendon pathologies. Past research found an association between prolonged pain and instability following treatment for ankle sprains with additional conditions, including syndesmotic widening and os trigonum syndrome, which can be treated together.2,4 Tibiofibular syndesmotic injuries occur in up to 16% of acute ankle sprains and have been associated with delayed recovery and limited function after a Broström-Gould repair. One study concluded that for patients with syndesmotic widening greater than 4 mm, further surgical intervention for the syndesmosis, in addition to the Broström-Gould, might be necessary.2 Os trigonum is a failure of the secondary ossification of the lateral tubercle of the talus to fuse and was found in 20% of patients with sprained ankles.4 This finding has been associated with chronic ankle sprains that do not resolve with standard treatment. A symptomatic os trigonum warrants additional preoperative planning for patients undergoing operative procedures for ankle sprains. We are presenting an alternative surgical technique that allows for the combined procedures of syndesmotic fixation, os trigonum excision, peroneal tendon debridement, and Broström-Gould repair through a single, 10 cm incision (see Video, Supplemental Digital Content1, https://links.lww.com/TIO/A97). The proposed technique has the advantage of tightening the lateral ankle ligaments, addressing peroneal tendon pathologies, correcting posterior impingement, and stabilizing the syndesmosis through a single incision, reducing the risk of skin bridge breakdown. If needed, a calcaneal osteotomy may also be performed through the same incision. TECHNIQUE The patient is given a regional block before entering the operating room for postoperative pain control. The patient is then placed supine on the operating table, and general anesthesia is administered. A tourniquet is applied around the ipsilateral thigh, a triangular bump is placed under the ipsilateral side of the patient’s torso, and bone foam is used to elevate the operative foot. The operative leg is prepped and draped in standard sterile fashion. The tourniquet is inflated in accordance with the patient’s blood pressure. A marking pen is used to identify the anterior, posterior, and distal borders of the fibula. A 10 cm curvilinear incision is made over the lateral aspect of the fibula and extended along the lateral malleolus, ending about 1 cm proximal to the 5th metatarsal base (Fig. 1A). Blunt dissection is performed to expose the periosteum over the distal fibula. The syndesmosis is stressed under fluoroscopy to confirm the diagnosis. A three-hole plate is positioned laterally over the distal fibula, directly over the periosteum. Placement is confirmed with fluoroscopy. A 3.5 mm cortical screw is inserted distally to secure the plate. Two Kirschner (K) wires are placed to stabilize the plate on the fibula. For each suture button system, the correlating K wire is removed, and a 3.5 mm drill is used to create a channel across the fibula and tibia under fluoroscopic guidance (AP and lateral view). The suture button is passed across the syndesmosis and tightened according to the manufacturer’s guidelines (Fig. 1B). In the provided case, we used two ArthrexTM knotless tightrope systems. The final placement of the suture buttons is confirmed using fluoroscopy.FIGURE 1: (A) Incision and superficial dissection. (B) Completed syndesmotic fixation. (C) Peroneus longus tendon. (D) Surgical field following excision of the peroneal tubercle. (E) Probe identifying the os trigonum. (F) Wire orientation in distal fibula. (G) Suture orientation for the Brostrom-Gould repair. (H) Completed closure of the superior peroneal retinaculum. (I) X-ray demonstrating final positioning of hardware.Attention is then brought towards the peroneal tendon debridement. The superior peroneal retinaculum is incised and a cuff is maintained for later repair. The peroneal tendon sheath is then incised and dissection is carried down to the peroneal tubercle. The peroneal tendons are visually inspected and, using a vessel loop, the peroneus longus tendon is retracted. If there is a low-lying peroneus brevis muscle belly, such as in this case, the tendon is debulked, and the low-lying muscle belly is removed. In this case, the peroneus longus had severe tendinosis. The peroneus longus tendon is elevated using an army navy and a 15-blade is used to remove the fibrous section, being careful not to violate the posterior wall of the tendon (Fig. 1C). Tubularization of the tendon is performed with 3-0 Ethibond in a running locking fashion (Fig. 1D). The knot is buried within the tendon to minimize irritation. The peroneal tendons are then retracted anteriorly and the posterior compartment of the ankle is identified. The fascia of the posterior compartment is split and the posterior fat pad is identified and removed. After removal of the fat pad, the os trigonum is identified under direct visualization and fluoroscopy, the flexor hallucis longus tendon is retracted. Better visualization of the os trigonum can be achieved with maximum dorsiflexion of the foot. The os trigonum is then excised (Fig. 1E and Fig. 2). In this case, the os trigonum was fibrocartilaginous. Removal was performed initially with a knife to excise the loose cartilaginous piece, and the bony piece was excised with an osteotome and rongeur. During this step, it is important to avoid going too medial to prevent injury to the flexor hallucis longus tendon and neurovascular structures, especially the tibial nerve. Irrigation is performed and the fascia is closed with 2-0 Monocryl.FIGURE 2: The os trigonum after successful removal with a knife and rongeur.Full-thickness skin flaps are then elevated above the superior peroneal retinaculum. The lateral branches of the sural and superficial peroneal nerve are identified and protected. Dissection is continued to expose the peroneus tertius fascia and the anterior talofibular ligament (ATFL). Using a 15-blade, the extensor retinaculum and ATFL are split at the level of the distal end of the lateral malleolus anteriorly. The proximal and distal capsule and retinaculum flaps are elevated off the fibula. A rongeur is used to clean the edges of the fibula and to roughen bone to the bleeding surface without shortening fibular length. Two K wires are inserted into the tip of the lateral malleolus and placement is confirmed with fluoroscopy (Fig. 1F). Two 3.5 mm suture anchors, each with four limbs of 0 fiber wire, are then placed. Six limbs are used to suture the extensor retinaculum and ATFL, with two limbs anterior and four mid-substance. The other two suture anchors are used to repair the calcaneofibular ligament (CFL) (Fig. 1G). To prevent irritation, the suture used to repair the CFL is passed anteriorly through the bulk of the ATFL. While keeping the foot in dorsiflexion and eversion, the suture limbs are tightened. The Gould modification includes passing the fiberwire through both the ATFL and the extensor retinaculum. The second layer of repair is completed by passing the fiber wire through the elevated periosteum, proximal to distal. The superior peroneal retinaculum is closed with 0-Vicryl suture (Fig. 1H). 4-0 Monocryl is used to close subcutaneous tissue, and 4-0 Nylon is used for the skin. A below-the-knee AO splint is placed with the ankle in dorsiflexion and eversion. The patient is scheduled for a 2-week follow-up in clinic for an incision site check, suture removal, and transition to a short leg non-weight bearing cast. The patient is kept non-weight-bearing for an additional four weeks. At 6 weeks, the patient is put into a walking boot and can begin progressive weight-bearing and physical therapy. EXPECTED OUTCOMES To our knowledge, this is the first technique describing the approach to syndesmotic fixation and lateral ankle ligament reconstruction, incorporating an os trigonum excision and peroneal tendon debridement, all through a single incision. A two-incision approach could be used for the same procedure: one on the dorsolateral ankle for the Broström-Gould and one more proximolateral for the syndesmosis. However, placing two incisions in close proximity poses the risk of skin bridge breakdown, wound dehiscence, and the need for future operations. It can be reasonably inferred that a single-incision approach to both procedures can mitigate the risks of wound complications while providing adequate exposure. This extensile approach also allows for the excision of an os trigonum, if present. While some surgeons prefer to remove the os trigonum arthroscopically or through a medial approach, removal through this lateral approach can shorten the operative time compared with arthroscopic removal and spares a medial approach through the sinus tarsi. In an unpublished series of nine patients (6 female, 3 male, mean age 39.1, mean BMI 35.6) who underwent lateral ankle ligament reconstruction and syndesmotic fixation according to the described technique, all patients reported improvement of presenting symptoms at a mean follow-up time of 6 months (Table 1). Complications included one patient with sural neuritis and one patient with superficial peroneal neuritis. Both patients’ symptoms resolved with conservative treatment. In addition, one patient required the removal of the syndesmotic screws due to stiffness, which were replaced with a suture tape construct. TABLE 1 - Outcomes of Single-Incision Brostrom-Gould Repair with Syndesmotic Fixation and Os Trigonum Excision Patient Sex Age BMI Follow-Up (mo) SPN neuritis Other complications 1 F 31 34.95 3 0 0 2 F 39 36.32 6 0 0 3 F 36 39 6 0 0 4 M 43 45.7 5 0 0 5 F 40 30.51 10 1 0 6 F 43 32.14 2 0 0 7 F 27 36.54 15 0 1 8 M 37 27.2 3 0 0 9 M 56 38.01 4 1 0 COMPLICATIONS Potential complications associated with this procedure include damage to surrounding neurovascular structures, recurrence of lateral ankle instability, and syndesmosis fixation failure. Careful identification and protection of the superficial peroneal and sural nerves can mitigate the risk of damage and postoperative symptoms. Although rare, the saphenous nerve and vein can be damaged during the syndesmotic fixation despite fluoroscopic guidance.1 Direct medial visualization of these structures can be performed if there is concern for iatrogenic injury. Recurrent lateral ankle instability can occur if the Broström-Gould repair fails. Revision Broström-Gould or conversion to a non-anatomic repair may be necessary if ankle instability symptoms persist.