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00005768-200606000-0000100005768_2006_38_1025_fujii_comparison_6article< 88_0_10_9 >Medicine & Science in Sports & Exercise©2006The American College of Sports MedicineVolume 38(6)June 2006pp 1025-1031Comparison of Modified Broström and Evans Procedures in Simulated Lateral Ankle Injury[CLINICAL SCIENCES: Clinically Relevant]FUJII, TADASHI1; KITAOKA, HAROLD B.2; WATANABE, KOTA3; LUO, ZONG-PING4; AN, KAI-NAN51Department of Orthopaedic Surgery, Takai Hospital, Tenri, JAPAN; 2Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN; 3Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo, JAPAN; 4Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX; and 5Orthopaedic Biomechanics Laboratory, Mayo Clinic, Rochester, MNAddress for correspondence: Harold B. Kitaoka, M.D., Department of Orthopaedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; E-mail: for publication November 2004.Accepted for publication November 2005.ABSTRACTPurpose: The purpose of this study was to compare the modified Broström and Evans procedures for simulated lateral ankle instability in cadaveric lower extremities.Methods: Six normal cadaveric ankles were loaded with inversion and internal rotation stress through the range of ankle flexion, and three-dimensional motion of the calcaneus and talus relative to the tibia were measured. An ankle stability testing device and a magnetic tracking system were used. Testing was performed in the intact condition, unstable condition after sectioning both the anterior talofibular (ATFL) and calcaneofibular ligaments (CFL), after the Gould modification of the Broström procedure, and after the Evans procedure.Results: With inversion loading, both operations resulted in a significantly more stable ankle-hindfoot complex (calcaneal-tibial) than the unstable condition, but there was restricted motion after the Evans operation from neutral to plantarflexion. Tibiotalar inversion motion approximated normal after both operations, but subtalar motion was markedly restricted in the Evans procedure throughout the range of ankle flexion. With internal rotation loading, the Broström operation stabilized the ankle-hindfoot joint complex in plantarflexion. The Evans operation improved internal rotation stability, but restricted motion in all positions. Both operations improved tibiotalar internal rotation stability, but not to normal. The subtalar internal rotation was the same as the intact condition after the Broström operation, but markedly restricted after the Evans operation through the range of ankle flexion.Conclusions: Both operations improved ankle-hindfoot stability, but neither was successful in restoring it to normal as determined with the ankle stability testing device. The Evans procedure improved stability at the expense of creating abnormal subtalar function. The Broström operation improved stability without excessively restricting subtalar movement, but was not effective in addressing the internal rotation laxity.There are numerous operative procedures designed to correct mechanical instability of the lateral ankle ligaments. Most of these operations have favorable clinical results, but there are contradictory results from different investigators. Consequently, it is difficult to arrive at a consensus as to the optimal surgical treatment for chronic lateral ankle instability.Two of the most commonly used surgical procedures are the Evans and the Broström techniques. The Evans procedure is an operation that involves peroneus brevis tenodesis, sectioning the tendon proximally, and transferring it through the lateral malleolus (7). It has been used worldwide for decades and has the advantage of being a relatively simple procedure that improves lateral ankle stability. Clinical results were generally very favorable with success rates of 50-97% (2-4,14,16,17,20,23,25,27-29).Bjorenheim et al. (4) reported that none of the 34 patients who underwent the Evans procedure were disturbed by decreased inversion. Barnum et al. (2) reported results in 20 patients with mean of 12.6-yr follow-up and concluded that it was reliable and effective, with 85% success. Korkala et al.(16) reported excellent or good results in 82% at 9- to 12-yr follow-up with little change compared with 2- to 3-yr follow-up.Some investigators raised concerns about the clinical results of the Evans procedure (13,14,18,19,22,24). Karlsson et al. (14) found that satisfactory early results deteriorated with time in 12 of 42 patients, overall functional results were satisfactory in only 50%, and osteophytes were present in most. Kristiansen (17) reported that only 33% of those engaged in athletic events had no ankle complaints. Kaikkonen et al. (13) found that only 52% were subjectively improved and noted decreased ankle motion. Labs et al. (19) found that 17% had an increase in arthrosis and also found decreased supination. Rosenbaum et al. (24) reported improved stability and excellent or good subjective results in 15 of 19 patients, but 11 had pain; there was an increase in osteophytes as well as decreased inversion. Nimon et al. (22) reported satisfaction of 98% of patients who underwent the Evans procedure, but 21 had decreased inversion, and 11 of 66 had degenerative changes. Discrepancies also were noted in the literature regarding the ability of the procedure to stabilize the ankle. Good stability in varus and anteroposterior directions was achieved by some investigators (23); however, Younes et al. (29) and Karlsson et al. (14) found that it was better for correcting talar tilt than anteroposterior instability.The Gould modification of the Broström procedure was popularized by Hamilton et al. (9) and involves direct repair of the ruptured lateral ankle ligaments and reinforcement with the extensor retinaculum. It has the advantage of improving stability while maintaining motion of the ankle and hindfoot (9). The clinical results were 96% successful with full motion. Several other authors reported favorable results with the Broström procedure without the Gould modification (10,12,15). However, Girard et al. (8) thought that the Gould procedure would eventually fail in patients who were overweight or hyperflexible or engaged in strenuous work or athletic activities. They recommended augmenting the operation with a peroneus brevis tendon transfer.We developed a method of critically evaluating ankle-hindfoot stability using a device, which applies a constant inversion or internal rotation force throughout the entire range of dorsiflexion-plantarflexion, while monitoring the three-dimensional motion of multiple bones simultaneously. The purpose of this study was to compare the modified Broström and Evans procedures for simulated lateral ankle instability in cadaveric lower extremities.MATERIALS AND METHODSFollowing institutional review board guidelines for obtaining fresh frozen cadaveric specimens from the department of anatomy, six fresh frozen cadaveric lower extremities without pathology were used in this study. The specimens were from three men and three women with a mean age of 75 yr (range, 67-91 yr). Two were left and four were right feet. The tibia and fibula were transected at the midleg level, soft tissues removed from the proximal portion, and then potted in an acrylic cylinder with polymethylmethacrylate. The specimen was secured to the frame of the ankle stability testing device.The ankle stability testing device (Fig. 1) enabled consistent loading of each anatomic specimen with a constant torque (in inversion or internal rotation) while moving the ankle though the entire sagittal plane range of motion. This apparatus enabled movement in rotation (inversion-eversion, internal rotation-external rotation, and plantarflexion-dorsiflexion) and translation (anteroposterior, mediolateral, and proximal-distal translations) in a global anatomic coordinate system of the hindfoot. The design allowed for unconstrained natural rotation of ankle and subtalar joints, whether or not the axis of the device is aligned anatomically. Plantarflexion-dorsiflexion was selected as the independent variable, and the other two rotational components (inversion-eversion and internal rotation-external rotation) were loaded to their maximal positions while the specimen was moved from extreme plantarflexion to extreme dorsiflexion.FIGURE 1-Modified Broström procedure. Drawing shows extensor retinaculum used to augment the direct repair of ATFL and CFL (not shown).The motions of the calcaneus relative to the tibia (ankle-hindfoot complex), the talus relative to the tibia (ankle), and the calcaneus relative to the talus (subtalar) were measured by a 3Space Fastrak System™ (Polhemus Navigation Sciences Division, McDonnell Douglas Electronics Company, Colchester, VT), which consisted of one magnetic three-axis source, four magnetic three-axis sensors, and an electronics unit. According to the manufacturer's specifications, this system has translational accuracy of 0.762-mm root mean square and angular accuracy of 0.15° root mean square. The ankle ligament testing device repeatability in two trials of inversion and also two trials of internal rotation condition demonstrated intraclass correlation coefficient of 0.95 or better in validation testing of calcaneal-tibial motion.A constant 1.7-N·m torque was applied to inversion or internal rotation to the intact foot, then the anterior talofibular (ATF) and calcaneofibular (CF) ligaments were sectioned to create the instability pattern commonly observed in patients with severe lateral ankle ligament sprains. Sectioning other ligaments such as the posterior talofibular ligament was not performed because this is rarely injured in lateral ankle sprains. The torque level was determined by preliminary tests that showed that further increase of torque did not significantly change the joint deformation. There was limited potential for specimen injury during testing with this torque level, and it was found to adequately stress the ankle with acceptable patient comfort during in vivo preliminary tests. Two operations, the Gould modification of the Broström (5) ligament reconstruction and the Evans (7) procedure, were performed on each specimen according to the literature. All reconstructions were performed by an experienced orthopedic surgeon (T.F.). The modified Broström operation was performed, then all sutures were removed, and the Evans procedure was then performed. The Broström procedure involved direct repair of ATFL and CFL. The extensor retinaculum was then used to reinforce the ligament repair (Fig. 2) by mobilizing the posterior margin of the retinaculum and securing it to the lateral malleolus. The Evans procedure (Fig. 3) involved peroneus brevis tenodesis, sectioning the tendon proximally, routing the tendon through a drill hole in the lateral malleolus, preserving its attachment to the base of the fifth metatarsal (7). The operations were performed in vitro in the identical way as they are conducted in vivo, with tendon tension adjusted to near-maximum level.FIGURE 2-Evans procedure with peroneus brevis tendon transfer.FIGURE 3-Ankle stability testing apparatus.Internal rotation and inversion angles of the calcaneus and talus were plotted verses the plantarflexion-dorsiflexion angle as determined using the tibial and calcaneal magnetic sensors. Two trials for each testing condition were recorded to evaluate reproducibility. Intraclass correlation coefficients were calculated on the trials for each specimen to assess the reliability of this testing. Data from the first of the two trials were used for subsequent analysis. Measurements at 20° plantarflexion, 0°, and 10° dorsiflexion of each curve were chosen for statistic analysis. Statistical analysis was performed with the Wilcoxon signed-rank test with a significance level of P < 0.05 with JMP (SAS Institute, Inc.)RESULTSAnkle-hindfoot complex (calcaneal-tibial) stability.The modified Broström procedure significantly improved internal rotation stability in the plantarflexion position compared to the injured condition in the plantarflexion condition, but was less stable than the intact and in the plantarflexion, neutral, and dorsiflexion conditions (Table 1). The Evans procedure restored internal rotation stability more effectively than the modified Broström in plantarflexion, neutral, and dorsiflexion ankle positions, but remarkably overcorrected or restricted the movement in neutral and dorsiflexion positions (Fig. 4).TABLE 1. Calcaneal-tibial motion (°, mean ± SD).FIGURE 4-Calcaneal-tibial (ankle-hindfoot complex) motion. A. Inversion stress, mean. B. Internal rotation stress, mean.The modified Broström procedure restored inversion stability in plantarflexion and neutral positions. The Evans procedure significantly overcorrected the inversion stability in plantarflexion and neutral positions.Talar-tibial stability.There was increased internal rotation stability in plantarflexion, neutral, and dorsiflexion in the modified Broström procedure and in neutral and dorsiflexion after the Evans procedure, but it still differed from normal (Table 2; Fig. 5).TABLE 2. Talar-tibial motion (°, mean ± SD).FIGURE 5-Talar-tibial (ankle) motion. A. Inversion stress, mean. B. Internal rotation stress, mean.There was increased inversion stability in plantarflexion and neutral after the modified Broström procedure and in plantarflexion, neutral, and dorsiflexion after the Evans procedure. The ankle was still less stable than the intact condition in dorsiflexion following the Evans procedure.Calcaneal-talar (subtalar) stability.The Evans procedure abnormally increased internal rotation stiffness in all positions tested (plantarflexion, neutral ankle flexion, dorsiflexion), whereas the modified Broström procedure did not significantly affect subtalar stability (Fig. 6; Table 3).FIGURE 6-Calcaneal-talar (subtalar) motion. A. Inversion stress, mean. B. Internal rotation stress, mean.TABLE 3. Calcaneal-talar motion (°, mean ± SD).The Evans procedure markedly increased inversion stiffness in plantarflexion and neutral positions. In contrast, the modified Broström procedure did not significantly restrict subtalar inversion mobility.DISCUSSIONThe present study demonstrated that both operations were able to improve the stability of the ankle, but the effectiveness of each procedure was dependent on the direction of the stress applied (inversion or internal rotation) and the position of the ankle in dorsiflexion-plantarflexion. Both procedures improved inversion stability. The modified Broström procedure did not cause restricted movement at the subtalar level. This is consistent with the success of the modified Broström procedure in elite athletes who require full mobility of the ankle and hindfoot, such as ballet dancers (9). The Evans procedure abnormally increased inversion stiffness particularly at the subtalar level. It is consistent with the clinical observation of restricted inversion motion after the Evans procedure. It is also consistent with the radiologic observation of degenerative changes or osteophyte formation in the ankle and hindfoot in longer-term studies; an indication of abnormal joint kinematics. Neither operation was successful in restoring normal internal rotation stability.Previous investigators reported laboratory-based studies involving the ankle reconstruction operations, with differing results (1,6,11,21,26). Hollis et al. (11) found that the subtalar motion was similar to the normal foot following the Evans procedure, but Colville et al. (6) and Rosenbaum et al. (26) noted a decrease in subtalar movement. Liu and Baker (21) and also Bahr et al. (1) reported a decrease in anterior drawer and talar tilt after the Broström procedure, but Rosenbaum et al. (26) and Colville et al. (6) noted that the operation did not correct the instability. These differing results could be explained by different and more variable methods of measuring stability and motion, such as with radiographs or goniometers. There were also differences in the previous testing techniques such as how specimens were loaded. Specifically in this study, ankle-hindfoot stability was measured for the full range of sagittal plane motion from plantarflexion to dorsiflexion in a consistent, repeatable mannerThe present study examined kinematics of the calcaneus and talus in the normal ankle ligament condition, the unstable ankle, and following two commonly performed reconstruction operations. The testing technique may be applicable for future studies, such as analysis of novel operations for ankle instability, for improving our understanding of subtalar instability, or for orthoses designed to treat ankle-hindfoot disorders.As with most in vitro biomechanical studies, there were limitations to the study. The effects of soft-tissue healing and patient adaptation could not be simulated. This study addressed static stability of the ankle with only the ATF and CF ligaments compromised to create the unstable condition. This injury condition was simulated, as these are the two ligaments that are most commonly affected in a severe lateral ankle ligament sprain with demonstrable instability. The posterior talofibular ligament is rarely injured. It is also possible that a severe twisting injury to the ankle may cause damage to other soft tissues, such as ligaments of the subtalar joint. The ligaments stabilizing the subtalar joint were not specifically analyzed in the present study, but could be the subject of additional studies in the future, using the same testing methods described. Other factors such as neuromuscular control of the ankle were not modeled in the present study but could be simulated in the future. 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