Ankle Ligament Reconstruction (Broström Procedure)

Why this approach — at MOS

Chronic lateral ankle instability is diagnosed too often without objective stress testing, and undertreated too often without a genuine trial of targeted rehabilitation. Before I recommend surgery, I confirm the diagnosis with standing AP and mortise X-rays, stress X-rays under fluoroscopy to measure talar tilt and anterior drawer, and usually MRI to assess ligament quality and identify any intra-articular pathology that would change the surgical plan.

I perform the Broström-Gould procedure as the standard technique because it is anatomic and uses the patient's own tissue. For patients with prior failed repairs or insufficient tissue, I discuss allograft-augmented reconstruction options. Arthroscopic-assisted Broström techniques are available and offer the advantage of a smaller incision and the ability to address intra-articular pathology simultaneously through the arthroscope.

Intraoperatively, I tension the repair with the ankle in slight dorsiflexion and neutral rotation — over-tightening the repair causes a stiff, uncomfortable ankle, while under-tightening risks residual instability. The goal is restoration of normal biomechanics, not maximum tightness. The Gould modification is always performed; the data supporting its additional stability in active patients is compelling.

Patients in the Germantown and broader Montgomery County area often present after having had two or three "bad" ankle sprains and being told to "just use a brace." When ligamentous stability cannot be restored non-operatively, the Broström procedure reliably returns patients to sport and prevents the progressive cartilage damage that chronic instability produces over time.

Who is a candidate?

Indications

• Chronic lateral ankle instability (≥3 recurrent sprains or persistent giving-way sensation over more than 6 months)
• Positive anterior drawer test and/or talar tilt test on examination
• Stress X-rays showing excessive talar tilt or anterior drawer compared to the contralateral ankle
• MRI or ultrasound confirming ATFL laxity/elongation or complete tear
• Failure of 3–6 months of supervised physical therapy targeting peroneal muscle strengthening and proprioception
• Athletes requiring reliable ankle stability to return to competitive sport

Contraindications

• Generalized ligamentous laxity (e.g., Ehlers-Danlos syndrome) — native tissue may be insufficient; allograft augmentation or alternative reconstruction techniques required
• Significant cavovarus foot deformity — the underlying foot alignment must be corrected simultaneously or the repair will fail
• Active local infection or open wound
• Prior failed Broström where ligament tissue is insufficient — revision reconstruction with allograft or tenodesis procedures may be needed
• Incomplete trial of conservative physical therapy and bracing

Conservative Treatment First

Chronic ankle instability should be treated non-operatively before surgery is recommended. The peroneal muscles are the dynamic stabilizers of the lateral ankle — strengthening them through physical therapy can compensate for stretched ligaments in many patients. A structured program of peroneal strengthening, proprioception training (balance board, perturbation training), and ankle bracing can provide adequate functional stability for daily activities and recreational sports.

Ankle bracing with a lace-up or semi-rigid orthosis helps prevent recurrent inversion and allows the peroneal muscles to respond without the ankle giving way. Brace use during high-risk activities is appropriate even long-term. Patients who achieve functional stability with bracing and remain symptom-free do not require surgery.

Surgery is recommended when a patient has completed a genuine 3–6 month course of physical therapy and continues to experience meaningful functional instability that limits activity. The diagnosis must be confirmed with objective testing (stress X-rays, MRI) before surgery.

The procedure

What Is the Broström Procedure (Ankle Ligament Reconstruction)?

The Broström procedure is surgery to repair the stretched or torn lateral ankle ligaments (ATFL and CFL) that cause chronic ankle instability — the feeling that the ankle "gives way" repeatedly. The surgeon tightens and reattaches the ligaments to their original bone insertions, restoring mechanical stability and eliminating recurrent sprains.

This procedure is for chronic ankle instability — not acute ankle fractures. Patients who have had an acute ankle fracture and require plate-and-screw fixation need a different operation (Ankle Fracture ORIF). The Broström procedure addresses ligament laxity from repeated sprains over time — not bone injury.

The lateral ankle is stabilized by three ligaments: the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The ATFL is the most commonly injured — it resists anterior drawer motion of the talus and is the primary stabilizer against inversion. The CFL lies beneath the peroneal tendons and resists talar tilt. After a significant ankle sprain, these ligaments can heal in an elongated position, creating permanent mechanical laxity. When this leads to functional symptoms — recurrent giving-way, chronic pain, difficulty on uneven terrain — surgery becomes appropriate.

The Broström procedure, first described in 1966, remains the gold standard operative treatment for chronic lateral ankle instability. The modification described by Gould adds the inferior extensor retinaculum as an additional reinforcing layer, improving stability especially in physically active patients. The procedure uses the patient's own tissue (the original ligaments), making it an anatomic repair rather than a reconstruction.

What Happens During the Broström Procedure?

Surgery is performed at an ambulatory surgery center as an outpatient procedure.

Anesthesia: A popliteal sciatic nerve block is performed for anesthesia and post-operative pain control. This may be combined with light sedation or general anesthesia according to patient and anesthesiologist preference. The block provides analgesia for 12–18 hours post-operatively.

Arthroscopic Phase (when performed): In patients with concurrent intra-articular pathology (osteochondral lesions, synovitis, loose bodies, impingement), ankle arthroscopy is performed first, through small portal incisions at the front of the ankle. This allows treatment of cartilage or synovial issues before the open ligament repair.

Positioning: The patient is supine with the operative ankle hanging off the end of the table, or positioned laterally depending on surgeon preference. A tourniquet controls bleeding.

Incision: A curved 4–6 cm incision is made over the distal fibula (the lateral ankle bone). The incision follows the course of the ATFL anteroinferiorly. The sural nerve (passing posteriorly) and branches of the peroneal nerve (anteriorly) are identified and protected throughout the case.

ATFL repair: The ATFL is identified at its fibular origin. In most chronic instability cases, the ligament is attenuated and stretched. The fibular attachment footprint is freshened with a small burr. Suture anchors (small titanium or absorbable devices) are placed in the anterior fibula. The ATFL is imbricated — folded on itself to shorten it — and the excess tissue is tied down to the anchor sutures with the ankle held in neutral dorsiflexion and slight eversion.

CFL repair: The CFL, located just beneath the peroneal tendons, is similarly identified, shortened, and secured.

Gould modification (standard): The inferior extensor retinaculum — a strong fibrous band lying just anterior to the fibula — is dissected free and advanced superiorly to overlay the repaired ligaments. This is sutured to the fibular periosteum as a reinforcing second layer and adds rotational stability that is particularly valuable in athletes.

Closure: The wound is closed in layers. A well-padded posterior splint holds the ankle in neutral dorsiflexion (not plantarflexion, which would stress the repair).

Recovery timeline

Frequently Asked Questions