Tag Archives: Modified Bröstrom stabilization

Surgical Correction of Subluxing Peroneal Tendons Utilizing a Lateral Slip of the Achilles Tendon: A case report

by Mark Mendeszoon, DPM, FACFAS, FAFAOM,1 , J. Todd McVey, DPM2, Adam MacEvoy, DPM3  

The Foot and Ankle Online Journal 2 (8): 3

Subluxation of the peroneal tendon can be either an acute or chronic condition. As an acute injury, it can quite often be misdiagnosed as a lateral ankle sprain. This case report describes a technique using the lateral slip of the Achilles tendon as a retinacular graft to repair subluxation and dislocation of the peroneal tendons.

Key words: Tubularization, Achilles tendon graft, modified Brostrom repair, subluxation, dislocation, peroneal tendons.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: July, 2009
Published: August, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0208.0003


The peroneal tendons course around the lateral ankle at the distal aspect of the fibula. These tendons which include the tendons of the peroneus longus and brevis move through a tunnel created of both fibrous and osseous structures. [2] The borders of this tunnel include the lateral malleolus, posterior talofibular ligament, calcaneal fibular ligament, and superior peroneal retinaculum. Both tendons run together until they are distal to the fibula where they split and enter separate sheaths. Most important to us is the superior peroneal retinaculum (SPR) which is the primary restraint to subluxation and dislocation of the peroneal tendons. [1,8,9]


First Described in 1803 by Monteggia, peroneal subluxation and dislocation can be categorized as either acute or chronic injuries. Most acute injuries are caused by a sudden dorsiflexion and inversion of the ankle while the peroneals are contracting. Acute injuries occur most often during sporting activities.

The most common injury occurs during downhill skiing. If the injury is left untreated, it can lead to chronic pain or ankle pain that will require surgical correction. Pain is caused by splitting or fraying of the peroneal tendons which occur when the tendon continues to sublux over the posterior lateral edge of the fibula causing micro tears to the tendon. Chronic injuries are also associated with patients who are prone to multiple ankle sprains. These sprains can lead to lateral ankle weakness which can lead to inflammation of the peroneal tendon sheath. [6,8,9] The sustained inflammation of the sheath can lead to weakening and stretching of superior peroneal retinaculum which will allow the peroneal tendons to leave the peroneal tunnel. Echard and Davis created a classification system for peroneal subluxation.

This system includes for subtypes which are as follows:

I-Periosteum is elevated form underlying malleolus.
II-Superior peroneal retinaculum is torn from the anterior insertion.
III-Superior peritoneal retinaculum is avulsed with a small piece of bone.
IV-Superior peroneal retinaculum is avulsed from posterior attachment and tendon dislocates.

Conservative treatment of this condition can be used however the literature shows there is a high failure rate for this course of action. [2] Most conservative treatment includes casting for 4-6 weeks. Other treatment includes taping which as a lower success rate than casting. Usually primary repair is indicated for tears in the tendon involving 50% or less. [11] Considering the majority of these patients are athletes, most want a speedy return to activity and expect a high success rate. [1,8,9,10]

Case Report

A male patient reported that he was racing his motocross bike when he landed a jump with his foot in an awkward position. He recalls extreme pain at his ankle and noted that a bone was protruding under his skin, which he states that he pushed the bone back in to place and went to the emergency room (ER).

At the ER it was noted that patient had significant swelling, pain on palpation, ecchymosis, popping sensation along with extreme instability. Patient was immobilized, obtained a magnetic resonance image (MRI) and sent to the office the next day for consultation. After educating the patient on conservative and surgical options, the patient chose the latter. MRI showed extreme poster lateral edema, and anterior talofibular ligament (ATFL) tear, avulsion fracture of fibula, with a high suspicion of SPR tear.

Clinical evaluation reveals a 5’11” male who is 195 lbs. The patient’s neurovascular status remains intact. There is significant ecchymosis, positive Mondor sign, pain on palpation of fibula, pain with range of motion and the fibula is mobile at the lateral ankle. Stress films in the operating room while the patient is under general anesthesia reveals a positive anterior drawer and talar tilt.

Surgical Technique

An incision is made over the lateral aspect of the leg following the peroneal tendons, approximately 10-12cm in length. (Fig 1.) Significant hematoma and disruption of the tissue is encountered during blunt dissection. The peroneal tendon sheath is completely ruptured, and the peroneus brevis is lying on top of the lateral aspect of the fibula. The peroneal retinaculum is ruptured with an associated fleck of bone. On closer inspection, the peroneal groove is noted to be disrupted, rough, and shallow.

Figure 1  10-12 cm incision along the peroneal tendons.

The calcaneofibular ligament is intact and stable, and the posterior capsule gapped open. The ATFL is attenuated and the origin is slightly disrupted. The peroneal tendons are intact distally.

The damaged peroneal tendon are then tubularized using #2 fiber wire and placed back onto the fibular groove (Figs. 3,4). Subluxation and popping of the tendon is still noted. Because of this a reconstruction using the lateral 20% of the Achilles tendon is performed. A transverse incision is made into the Achilles tendon approximately 8 cm proximal to the insertion. The tendon is split distally and dissected through blunt means and used to protect the sural nerve and lateral structures. The low-lying muscle belly of the peroneus brevis, which is dissected away from the tendon just enough to pass the Achilles slip through its course. (Fig. 2) The cut end of the Achilles tendon is passed under the muscle belly of the peroneus brevis and over the peroneus longus and brevis tendons. (Figs. 5 and 6)

Figure 2  Resection of low lying muscle belly.


Figures 3 and 4 Repair of the peroneal tendons through tubularization.


Figures 5 and 6  A tunnel is made through the peroneus brevis muscle belly and the slip of the Achilles tendon is then passed over the peroneal tendons.

This bridge of tendon over the peroneal tendons is then anchored to the lateral malleolus using an Arthrex® bioabsorbable anchor. (Figs. 7,8 and 9) At completion of this reconstruction, there is no sign of subluxation of the peroneal tendons.

The wound is then irrigated and a modified Brostrom technique is used to repair and tighten the ligaments in a pants-over-vest fashion. This greatly increases the tension strength of the repair. The wound is then closed in layers.


Figures 7, 8 and 9  Bone anchor is used to anchor the repair.  The procedure is strengthened with a Modified Brostrom repair.


There have been many options reported for surgical repair of peroneal subluxation or dislocation. These include direct repair of peroneal retinaculum, reconstruction of peroneal retinaculum, bone block (lateral malleolus, sliding graft), and groove deepening and rerouting procedures. [1,2,4,6,9]   Each of these procedures have their strengths and weaknesses. Acute repair of the superficial peroneal retinaculum is a simple repair however it may not be able to fix the underlying problem if there is a shallow grove, or the superior peroneal retinaculum itself is inherently weak due to prolonged inflammation. Reconstruction of the peroneal tendon can be accomplished using the peroneus brevis, plantaris, and/or Achilles tendons. There have been few studies reported on these techniques. A concomitant soft tissue procedure is a rerouting technique using the calcaneal fibular ligament. Bone block procedures incorporate part of an osteotomy used to deepen the fibular grove. This was first described by Kelly, and then modified by DuVries. [1,6,9,10] Complications associated with these techniques include graft fracture, tendonitis, pain and re-subluxation. Groove deepening procedures are performed by removing bone from the posterior aspect of the fibula. The result of deepening this grove is a more stable tunnel for the peroneus brevis and longus tendon sheath for gliding.

Peroneal tendon subluxation and dislocation is a condition which can be easily misdiagnosed as an ankle sprain and may cause a chronic painful condition requiring surgical intervention. As foot and ankle specialists we need to have a high suspicion, particularly in the younger athletic patients prone to such injuries.  The two most inherent causes of peroneal subluxation are multiple lateral ankle sprains and a shallow peroneal grove at the distal aspect of the tibia. Conservative treatment for this condition does not report a high success rate. The patient healed satisfactorily utilizing a lateral slip of the Achilles tendon in a tissue transfer technique and at the short term 6 month post op visit the patient had no complaints of pain.


1. Butler BW, Lanthier J, Wertheimer SJ: Subluxing peroneals: A review of the literature and case report. J Foot Ankle Surg 32: (2):134 – 139, 1993.
2 Oliva F, Ferran N, Maffulli N: Peroneal retinaculoplasty with anchors for peroneal tendon subluxation. Bull Hosp Joint Disease 63: (3 – 4): 113 – 116, 2006.
3. Ferran NA, Maffulli N, Oliva F: Management of recurrent subluxation of the peroneal tendons. Foot Ankle Clinics 11: (3) 465 – 474, 2006.
4. Kollias SL, Ferkel RD: Fibular grooving for recurrent peroneal tendon subluxation. Am J Sports Medicine 25: (3):329 – 335, 1996.
5. Brage ME, Hansen ST Jr: Traumatic subluxation/dislocation of the peroneal tendons. Foot Ankle Online 13: (7): 423 – 431, 1992.
6. Tan V, Lin SS, Okereke E: Superior peroneal retinaculoplasty: a surgical technique for peroneal subluxation. Clinical Ortho Rel Res [serial online] 410: 320 – 325, 2003.
7. Krause JO, Brodsky JW: peroneus brevis tendon tears: Pathophysiology, surgical reconstruction, and clinical results. Foot Ankle Int 19: (5): 271 – 279, 1998.
8. Ferran NA, Maffulli N, Oliva F: Management of recurrent subluxation of the peroneal tendons. Foot Ankle Clinics [serial online]11: (3):465 – 474, 2006.
9. Niemi WJ, Savidakis J Jr, DeJesus JM: Peroneal subluxation: a comprehensive review of the literature with case presentations. J Foot Ankle Surg 36: (2): 141 – 145, 1997.
10. Porter D, McCarroll J, Knapp E, Torma J: Peroneal tendon subluxation in athletes: fibular groove deepening and retinacular reconstruction. Foot Ankle Int 26: (6): 436 – 441, 2005.
11. Heckman DS, Reddy S, Pedowitz D, Wapner KL, Parekh SG: Operative treatment for peroneal tendon disorders. J Bone Joint Surg 90A: (2): 404 – 418, 2008.
12. Mendicino RW, Orsini RC, Whitman SE, Catanzariti AR: Fibular groove deepening for recurrent peroneal subluxation. J Foot Ankle Surg 40: (4):252 – 263, 2001.

Address correspondence to:Adam MacEvoy, DPM. PGY III, Department Of Veterans Affairs. Louis Stokes Cleveland Medical Center. Podiatry Surgery . Cleveland Ohio 44106. (216) 791-3800 Ext 5891

1 Precision Orthopedics, 150 7th Ave, Chardon , Ohio 44024.
2 Department Of Veterans Affairs. Louis Stokes Cleveland Medical Center
Podiatry Surgery. Cleveland, Ohio 44106.
3 PGY III, Department Of Veterans Affairs. Louis Stokes Cleveland Medical Center. Podiatry Surgery . Cleveland, Ohio 44106.

© The Foot and Ankle Online Journal, 2009

Augmented Bröstrom Repair Using Biologic Collagen Implant: Report on 9 Consecutive Patients

by Robert Fridman, DPM, AACFAS1, Jarrett D. Cain, DPM, AACFAS2, Lowell Weil, Jr., DPM, MBA, FACFAS3

The Foot & Ankle Journal 1 (7): 4

The Modified Bröstrom stabilization is commonly performed for chronic lateral ankle injuries. However, tissue viability, chronic injury, and/or injury severity may require a non-anatomic repair necessitating a tendon transfer. We present a series of 9 consecutive cases of Modified Bröstrom stabilization with OrthADAPT™ Bioimplant augmentation with 9 month follow-up. The average pre-operative Visual Analog Pain Score (VAS) was 5.78 out of 10 (range 5-8, SD 1.09). The mean duration of physical therapy was 2.3 months (range 6 weeks – 3 months). The mean length of time from surgery to discharge from care was 4.4 months (range 4-6 months). VAS was reduced to an average of 1.89 post-operatively at time of discharge from care (range 0-3, SD 1.05). The results were statistically significant (p>0.0001) at a 95% confidence interval. We conclude that the OrthADAPT™ Biologic Collagen provides support for augmentation and enhance the stability of the Modified Bröstrom procedure. Additionally, it may prevent the need for tendon transfer and its inherent complications.

Key words: Modified Bröstrom stabilization, OrthoADAPT™ Biologic collagen, chronic lateral ankle injury

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: May 2008
Published: July 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0107.0004

The Modified Bröstrom stabilization is a common anatomic reconstruction performed for chronic lateral ankle injuries of the anterior talofibular and calcaneofibular ligaments. [1] At times, tissue viability, injury chronicity, and/or severity of injury may require a non-anatomic repair (i.e., Evans Tenodesis), necessitating a tendon transfer. [2,3]

This creates a need for additional surgery and rehabilitation with all its associated complications. [4,5,6] A novel use of a biologic collagen implant (OrthADAPT™ Bioimplant, Pegasus Biologics, Irvine, CA) is described, which strengthens the Bröstrom-Gould repair and obviates the need for additional tendon harvesting.

The OrthADAPT™ Biologic Collagen Implant is a biologic scaffold that provides support for augmentation by fortifying and promoting tissue ingrowth to enhance the stability of the reconstruction procedure.

The purpose of this paper is to illustrate a new surgical technique using the Pegasus OrthADAPT™ Bioimplant for augmentation of the modified Bröstrom procedure for reconstruction of the lateral ankle ligament complex. A case series of 9 patients with 9-month follow-up is also presented.

Materials and Methods

The procedure is performed in the supine position under sedation with local infiltration. A roll is placed under the ipsilateral hip to allow for internal rotation of the leg and easy access to the surgical site. A high-ankle tourniquet is used for hemostasis. The incision is made just below the tip of the distal fibula and extended dorsally across the skin tension lines along the anterior fibula.

A controlled depth incision is made mimicking the initial skin incision. (Fig. 1)

Figure 1 Incision is made over the ATFL.

Care is taken to prevent violating the subtalar joint, and proper retraction is used to avoid the peroneal nerve, artery, and tendons. The ankle joint is identified using a 25-guage needle or via fluoroscopy. The anterior lateral ankle capsule and ATFL are sectioned and reflected proximally. (Fig. 2)

Figure 2  Anterolateral ankle capsule and ATFL sectioned.

The lateral talar dome may be inspected for the presence of any osteochondral lesions or osteophytes, and are corrected if present.

The foot is held is maximal eversion and the ligament is repaired as a Modified Bröstrom in a pants-over-vest fashion using 2.0 FiberWire®. (Fig. 3)

Figure 3  Pants-over-vest repair of the ATFL.

The calcaneofibular ligament is examined and primarily repaired, if needed, by reefing the tendon and suturing it onto itself. A 1x10cm strip OrthADAPT™ implant is prepared according to the manufacturer directions and is used for the repair. (Fig 4)

Figure 4   OrthADAPT™ implant strip.

Two hemostats are placed at both ends of the strip and are twisted to make a cable. (Fig 5)

Figure 5   OrthADAPT™ implant is fashioned into a cable.

One end of the strip is sutured to the distal end of the ATFL using 2.0 FiberWire®. A hemostat is placed through the repaired ATFL and the OrthADAPT™ Bioimplant cable is fed and drawn through. (Figs. 6, 7)

Figure 6   Hemostats are placed under the repaired ATFL to fascilitate weaving of the implant.

Figure 7   The implant is woven across the repaired ATFL.

This maneuver is repeated 3-4 times over and under the repaired ATFL and sutured to the proximal end of the ATFL. Additionally, a 4×4 sheet of OrthADAPT™ Bioimplant may be used as a patch over the repair. (Fig 8)

Figure 8   OrthADAPT™ implant patch over the repair.

This may minimize adhesions between the primary repair and the skin and impart additional security and strength. 4.0 FiberWire® is used in a vertical mattress suture pattern to secure the patch to over the repair. Skin closure is obtained using absorbable sutures and adhesive strips. (Fig 9)

Figure 9   Skin closure.

Post-Operative Protocol

The patient is maintained in a non-weight bearing short-leg cast with slight inversion for the initial first 3 weeks, and then progresses to a walking boot for the next 3 weeks. An intense physical therapy protocol is initiated after the cast is removed. A Stromgren® ankle brace is used for the next 6 weeks and with activity for the next 6 months. Non-contact sports may be initiated after 6 weeks, with any activity restrictions lifted at 3 months.


Nine cases of augmented Bröstrom repair using OrthADAPT™ implants were performed from April 2006 to September 2007. All cases were unilateral; 6 had chronic ankle instability and 3 were acute-on-chronic in nature. Seven patients were female and two were male. The age range was between 24-58 years old. Patients who had associated injuries or needed additional surgery, such as peroneal augmentation, were excluded from the study.

A Wong-Baker Faces Visual Analog Score (VAS) was administered to each patient and recorded pre-operatively and at each post-operative visit. The average pre-operative VAS was 5.78 out of 10 (range 5-8, SD 1.09). The average duration of physical therapy was 2.3 months (range 6 weeks – 3 months). The average length of time from surgery to discharge from care was 4.4 months (range 4-6 months). VAS was reduced to an average of 1.89 post-operatively at time of discharge from care (range 0-3, SD 1.05). The results were statistically significant (p>0.0001) at a 95% confidence interval.

There was one complication in this series that resulted in an explant. The patient complained of an “overstuffed” feeling in the area of the repair which was causing irritation in shoes. There was skin breakdown which exposed the patch repair. The patient was brought into the operating room and the patch was removed. Upon inspection, there was no issue with the weave portion of the repair, and it was left intact. The time from implant to explant was 3 months and this subsequently healed uneventfully.


Lateral ankle sprains are a common injury and account for 15% to 25% of all musculoskeletal injuries. [7] The anterior tibiofibular ligament (ATFL) is the most frequently sprained ligament in the body and has a 3:1 ratio of injury when compared to the calcaneofibular ligament (CFL). Most patients do well with conservative treatment and rehabilitation, and are able to return to function relatively soon after injury. [8] However, 10 to 30% of this population may develop chronic instability and repeated injuries. [9] The most common complaint is pain, swelling, and tenderness over the lateral ligament complex. [10]

The integrity of the ankle ligaments should be assessed on physical examination. This examination can be difficult at times due to patient guarding. A high ankle block with lidocaine or bupivicaine may aid with patient compliance to the examination.

A positive anterior drawer sign of >5mm than the contralateral side or 10mm of absolute translation indicates that there has been compromise of the ATFL. [11] A talar tilt of <10 degrees indicates injury to the CFL. Figure 10 demonstrates a positive talar tilt on fluoroscopic examination.

Figure 10   Positive talar tilt on fluoroscopic examination.

It is also important to investigate and address any associated injuries such as anterolateral impingement lesions, peroneal tendon injury and peroneal retinaculum pathology. [10]

Surgery is considered when conservative management has not produced successful results, and can be categorized into anatomic and non-anatomic procedures. The most commonly performed anatomic technique is the Bröstrom or Modified-Bröstrom Procedure, and has yielded very good results. [12,13] The benefits of performing anatomic repair include the utilization of local host anatomy, a simple surgical approach, and few complications However, the anatomic ligament repairs have less success with increased length of symptoms, history of previous surgery, and ligamentous laxity as its relies on potentially poor or lax local tissues to restore normal resistance to anterior translation and inversion. [14,15]

Girard, et.al, described a Modified Bröstrom-Evans which uses the anterior one-third of the peroneus brevis tendon in the general patient population as an added static restraint. [16]

Others have promoted the use of graft materials to reinforce the repair, such as plantaris tendon, fascia lata, and toe extensors. [17] The disadvantages of using autograft tendon include morbidity associated with harvesting, muscle weakness in the area where the graft was obtained, and increased surgical time required to harvest and prepare the graft before implantation. [18] In contrast, allograft materials may help improve recovery time. In this instance, operative time is less because the graft preparation and primary surgical approach may be done simultaneously without donor site morbidity. The disadvantages of allograft may include a slower incorporation rate, increased inflammation and the possibility for disease transmission. [18]

Non-anatomic repairs utilize tenodesis procedures to restrict ankle motion without repair of the ligaments of the ankle. [17] While these procedures increase stability, they also have increased morbidity and reduce ankle and subtalar motion. [7]

Our rationale for using the OrthADAPT™ implant to enhance the primary repair is to harness the benefits of an allograft augmentation, without the risks of disease transmission and increased inflammation. The OrthADAPT™ implant is derived from equine pericardium and functions as a resorbable scaffold to promote healing in damaged or diseased tissues. The cross-linking sterilization method enables it to withstand enzyme degradation, thereby providing durability, with enhanced tensile strength, suture pull-out strength, and burst strength test. [19] Our results are favorable when compared with other autograft materials that have been reported in the literature. [17]


The OrthADAPT™ Biologic Collagen Implant is a biologic scaffold that provides support for augmentation by fortifying and promoting tissue ingrowth to enhance the stability of the Modified Bröstrom procedure. Additionally, it may prevent the need for tendon transfer and its inherent complications.


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Address correspondence to: Dr. Robert Fridman, DPM, AACFAS
Foot Associates of New York, 60 East 56th Street, New York, NY 10022.
Email: RFridmanDPM@aol.com

1Lecturer, Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY; Private 2Practice, Foot Associates of New York, NY. 10022.
3Submitted as Fellow, Weil Foot and Ankle Institute, Des Plaines, IL. 60016.
4Fellowship Director, Weil Foot and Ankle Institute, Des Plaines, IL. 60016.

© The Foot & Ankle Journal, 2008