Biomechanical evaluation against calcaneofibular ligament repair in the Brostrom procedure: A cadaveric study

The modified Brostrom procedure is commonly recommended for reconstruction of the anterior talofibular ligament (ATF) and calcaneofibular ligament (CF) with an advancement of the inferior retinaculum. However, some surgeons perform the modified Bostrom procedure with an semi-single ATF ligament reconstruction and advancement of the inferior retinaculum for simplicity. This study evaluated the initial stability of the modified Brostrom procedure and compared a two ligaments (ATF + CF) reconstruction group with a semi-single ligament (ATF) reconstruction group. Sixteen paired fresh frozen cadaveric ankle joints were used in this study. The ankle joint laxity was measured on the plane radiographs with 150 N anterior drawer force and 150 N varus stress force. The anterior displacement distances and varus tilt angles were measured before and after cutting the ATF and CF ligaments. A two ligaments (ATF + CF) reconstruction with an advancement of the inferior retinaculum was performed on eight left cadaveric ankles, and an semi-single ligament (ATF) reconstruction with an advancement of the inferior retinaculum was performed on eight right cadaveric ankles. The ankle instability was rechecked after surgery. The decreases in instability of the ankle after surgery were measured and the difference in the decrease was compared using a Mann-Whitney U test. The mean decreases in anterior displacement were 3.4 and 4.0 mm in the two ligaments reconstruction and semi-single ligament reconstruction groups, respectively. There was no significant difference between the two groups (P = 0.489). The mean decreases in the varus tilt angle in the two ligaments reconstruction and semi-single ligament reconstruction groups were 12.6° and 12.2°, respectively. There was no significant difference between the two groups (P = 0.399). In this cadaveric study, a substantial level of initial stability can be obtained using an anatomical reconstruction of the anterior talofibular ligament only and reinforcement with the inferior retinaculum. The modified Brostrom procedure with a semi-single ligament (Anterior talofibular ligament) reconstruction with an advancement of the inferior retinaculum can provide as much initial stability as the two ligaments (Anterior talofibular ligament and calcaneofibular ligament) reconstruction procedure.