When chronic lateral ligamentous instability remains despite conservative treatment, the surgeon must choose between a multitude of operative methods for surgical stabilization. For most cases of chronic ankle instability in the athletic population, the modified Brostrom technique (answer #1) is preferred. The modified Brostrom procedure is an anatomic reconstruction of the lateral ankle ligaments (ATFL and/or CFL) and augmentation with the inferior extensor retinaculum. Messmer at al showed at a mean follow-up of 34.5 months (minimum of 18 months), twenty patients (91%) reported a good or excellent functional outcome with the modified Brostrom procedure. Krips et al looked at anatomical reconstruction and tenodesis in the treatment of chronic anterolateral ankle instability in a retrospective multicenter study. They found superior results in anatomical reconstruction compared to tenodesis in regards to stability (anterior drawer test and talar tilt & anterior talar subluxation on stress XR) and degenerative changes. They concluded that when compared with anatomical reconstruction, a tenodesis leads to inferior results in terms of functional and mechanical stability, as well as overall satisfaction at long-term follow-up. The Evans procedure (answer #1) is a nonanatomic reconstruction as the tendon weave does not recreate the ATFL or CFL but lies somewhere in between. It involves harvesting either half or the entire peroneus brevis tendon proximally and leaving it attached to the fifth metatarsal base distally. The free proximal portion is then passed anterior to posterior through a drill hole in the distal fibula or placed over the anterior fibula and sutured to the periosteum.
Osteotomies are generally reserved when dealing with abnormal foot shapes. Hindfoot varus can be treated with a valgus producing calcaneal osteotomy. Hindfoot varus due to a plantar flexed 1st metatarsal (confirmed with the Coleman block test) can be treated with a dorsiflexion osteotomy of the 1st metatarsal.
Krips R, van Dijk CN, Halasi PT, Lehtonen H, Corradini C, Moyen B, Karlsson J. Long-term outcome of anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a multicenter study. Foot Ankle Int. 2001 May;22(5):415-21.
PMID:11428761 (Link to Abstract)
Messer TM, Cummins CA, Ahn J, Kelikian AS. Outcome of the modified Broström procedure for chronic lateral ankle instability using suture anchors. Foot Ankle Int. 2000 Dec;21(12):996-1003.
PMID:11139039 (Link to Abstract)
Li X, Killie H, Guerrero P, Busconi BD. Anatomical reconstruction for chronic lateral ankle instability in the high-demand athlete: functional outcomes after the modified Broström repair using suture anchors. Am J Sports Med. 2009 Mar;37(3):488-94.
PMID:19251684 (Link to Abstract)