All-Inside Endoscopic Broström-Gould Technique

Abstract

Ankle sprain is the most frequent sports trauma. Surgical treatment is needed in case of chronical instability, after failure of conservative treatment. The technique established today worldwide consists in repairing the ligament (Broström technique) and strengthening the repair by adding extensor retinaculum (Gould technique). An arthroscopic technique recently has been developed; nevertheless, no published technique has proposed a total endoscopic Broström technique associated with a Gould augmentation because of difficulty in visualizing the retinaculum by anterior ankle arthroscopy. Lateral ankle endoscopy can provide a view of this area that is superior to open surgery. In this technique, the procedure is able to be performed safely and reproducible under perfect viewing. The purpose of this study is to describe an all-inside endoscopic Broström-Gould technique.

Fig 1

Arthroscopic portal. The patient is placed in the lateral decubitus position with the pelvis slightly rotated 30° posterior (Position 1). (A-B) The anteromedial portal is made in a position of dorsiflexion that shifts tibialis anterior tendon laterally, to have a better view of the lateral gutter. (C-D) The anterolateral portal is made between malleolus and spotlight when the arthroscope is positioned in the lateral gutter.

Fig 2

Endoscopic lateral portal. Portal 3 is the lateral endoscopic portal, made 1 cm anteriorly to the mid-distance between the tip of the fibula and the base of the fifth metatarsal. (LM, lateral malleolus; 5th M, 5th metatarsal.)

Fig 3

Arthroscopic preparation of the lateral gutter. (A) View of the lateral gutter. The red line shows the superior limit of the ATFL that is dissected with a beaver blade. (B) After complete preparation of the malleolus, peel off the ATFL and shave the footprint with the shaver. 1, Placement of the anchor for the ATFL. 2, 3, Placement of the anchor for the retinaculum. (ATFL, anterior talofibular ligament; Mal, lateral malleolus.)

Fig 4

Endoscopic dissection. (A) The dissection starts with a smooth trocar to make a working space between the skin and retinaculum. (B) The scope is inserted to portal 3 looking in the direction of portal 2. (C) The view after complete preparation (1 is the suture of the first anchor of the malleolus). (D) The superior view between the malleolus and retinaculum. (E) The view with the scope passing through the window made by portal 2 between the malleolus and the retinaculum. (Mal, lateral malleolus; RET, retinaculum; Tal, lateral side of talus.)

Fig 5

Retinaculum fixation with 2 anchors. (A) Passing the suture through the retinaculum with a complete view. (B) Four strands from 2 anchors. The knot is made outside the joint with 2 strands (1, 2). (C) By pulling on the 2 strands (3, 4 orange arrows), the knot is going down (red arrows) via the pulley effect created by the anchors. (D) Final aspect after the other knot was made with the other strands (3, 4). (Ret, retinaculum.)

Fig 6

ATFL fixation. (A) The suture of the anchor is set in the Mini Scorpion to pass the ATFL. (B) The suture passing the ATFL. (C-D) The suture passing the ATFL is passed into the loop to obtain a lasso around the portion of ATFL. (E) ATFL is drawn into the malleolus by pulling the other suture of the anchor. Then, the ATFL is fixed. (ATFL, anterior talofibular ligament.)