Overview
The modified Brostrom-Gould operation restores lateral ankle stability by repairing the native anterior talofibular ligament (ATFL) and, when indicated, the calcaneofibular ligament (CFL), then reinforcing the repair with the inferior extensor retinaculum. It is an anatomic repair that depends on usable local tissue. Chronic giving way should be assessed together with pain, alignment, peroneal tendon function and associated intraarticular disease; tightening the ligaments alone may leave an independent source of pain untreated.
Campbell recommends the modified Brostrom procedure for moderate or severe chronic instability when the remaining ligament tissue is adequate. Its detailed Brostrom-Gould technique is presented in the acute ligament repair section; the operative principles below are applied in the context of the chapter's separate recommendations for chronic instability. (Campbell, Chapter 94.)
Indications and Procedure Selection
Consider repair for symptomatic chronic lateral instability that remains disabling despite a structured program of muscle strengthening, proprioceptive rehabilitation and appropriate bracing. Symptoms and demonstrable laxity should fit the same diagnosis. Recurrent sprains alone do not establish that a native tissue repair will be sufficient.
Finding | Implication for planning |
|---|---|
Moderate or severe instability with adequate native tissue | Anatomic Brostrom-Gould repair is a suitable option in the chapter's treatment framework. |
Generalized laxity, poor tissue or failed previous repair | Consider augmentation or anatomic tendon graft reconstruction rather than relying on weak tissue. |
Persistent pain, catching or joint swelling | Investigate chondral injury, loose bodies and other intraarticular causes. |
Peroneal symptoms or weakness | Look for associated tendon disease, including a peroneus brevis split tear. |
Combined ankle and subtalar instability | Define the full instability pattern before choosing the reconstruction. |
The chapter discusses suture tape as a possible adjunct to primary repair and tendon augmentation for selected patients. These are additional strategies with their own indications, rather than obligatory components of every Brostrom-Gould repair. (Campbell, Chapter 94.)
Preoperative Assessment and Planning
Document the original injury, frequency of giving way, limitations in daily and sporting activity, prior rehabilitation and any previous operation. Examine lateral ligament laxity and distinguish mechanical instability from weakness or proprioceptive dysfunction. Assess the ankle and subtalar joints as well as the peroneal tendons. Review imaging for the ligament injury and associated articular disease, using stress assessment where needed to characterize laxity.
Plan for the possibility that the tissue encountered will not support a durable direct repair. Discuss the potential need for augmentation or reconstruction before surgery. A low threshold for concomitant arthroscopic evaluation is appropriate when intraarticular pathology is suspected, even if advanced imaging has not demonstrated a lesion. (Campbell, Chapter 94.)
Setup and Structures at Risk
Prepare the limb so that the lateral malleolus, peroneal tendons and anterolateral joint can be accessed and the ankle can be moved during repair assessment. Have the planned nonabsorbable sutures and bone fixation options available. If arthroscopy or graft reconstruction may be needed, incorporate those requirements into the setup.
The superficial peroneal nerve branches cross the anterior part of the exposure, often close to the talar end of the ATFL. The sural nerve lies near the peroneal tendons posteriorly. The CFL passes deep to the peroneal tendons. These relationships should guide deliberate superficial dissection and retraction rather than blind passage of instruments. Preserve superficial veins where feasible. (Campbell, Chapter 94.)
Surgical Technique
1. Exposure and protection
Use a curved lateral incision that allows access to the distal fibula and the lateral ligament complex. Develop the exposure carefully, identifying and protecting the superficial peroneal nerve branches anteriorly and the sural nerve near the peroneal tendons. Expose the capsule and identify the lateral portion of the inferior extensor retinaculum. Mobilize enough retinacular tissue for subsequent reinforcement without losing the tissue required for repair.
2. Define ligament quality and associated lesions
Identify the ATFL within the anterior capsular thickening and trace the CFL beneath the peroneal tendons. Establish whether the tissue is attenuated, torn or detached from bone. Evaluate the peroneal tendons for a split lesion and inspect the accessible joint for loose bodies, entrapped tissue and articular injury. Treat associated pathology according to its own findings and operative plan.
3. Repair the native ligament complex
Mobilize the ligament remnants sufficiently to restore their attachments. Campbell describes subperiosteal mobilization from the distal fibula when the ligaments are continuous but elongated. Approximate torn ends with appropriate nonabsorbable sutures, or secure a bone avulsion to its attachment using transosseous fixation or a small suture anchor. Select the construct according to the actual attachment injury and tissue quality. Do not substitute excessive tension for inadequate tissue.
4. Add the Gould reinforcement
Bring the mobilized proximal lateral edge of the inferior extensor retinaculum over the repaired ligament complex and attach it to the distal fibula. This supplements the anatomic ligament repair. If additional augmentation was planned and is indicated by the findings, complete it while preserving appropriate ankle motion and avoiding overconstraint.
5. Final assessment and closure
Reassess stability and motion after completing the repair. Confirm that protected nerves and tendons are free of the repair and that associated pathology has been addressed. Repair the capsule and peroneal sheath as required, close the wound and apply the protective splint. Campbell describes a posterior plaster splint with a U-shaped stirrup, the ankle neutral in the sagittal plane and mildly everted. (Campbell, Chapter 94, Technique 94.3.)
Postoperative Care
Protect the wound and repair while swelling settles. The chapter's regimen for Technique 94.3 limits prolonged dependent positioning during the first few days. At approximately two weeks, sutures are removed and touch-down weight bearing in a walking boot with crutches and gentle active motion without inversion begin. By five weeks, the described progression permits full weight bearing without crutches and starts formal physiotherapy. Inversion beyond neutral is restricted until eight weeks.
This schedule describes the textbook repair protocol. Progression must account for tissue quality, any augmentation or reconstruction, and concomitant tendon or cartilage procedures. Rehabilitation should restore motion, strength and proprioception without prematurely stretching the lateral repair. (Campbell, Chapter 94.)
Complications and Troubleshooting
Nerve symptoms: prevent traction, entrapment or injury of superficial peroneal branches and the sural nerve through direct identification and controlled dissection.
Recurrent instability: reconsider tissue quality, the extent of ligament injury, generalized laxity and the suitability of direct repair.
Persistent lateral pain: investigate an untreated peroneus brevis split tear or associated joint disease rather than assuming every symptom represents recurrent ligament failure.
Stiffness or overconstraint: assess motion and tension before closure and protect the repair without unnecessary prolonged immobilization.
Wound problems: preserve the soft tissue envelope and monitor the lateral incision during early follow-up.
Technical Pearls
Choose direct repair because the tissue can support it, not simply because it is the smallest reconstruction.
Identify the retinaculum early so that the Gould reinforcement remains available.
Look beneath the peroneal tendons to understand the CFL injury and inspect the tendons themselves.
Separate the goal of restoring stability from the treatment of associated cartilage or tendon pain.
Match rehabilitation to the actual operation performed.
References
Richardson DR. Sports injuries of the ankle. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2026. Chapter 94, lateral ligament repair and chronic instability, pp. 4149–4152; Technique 94.3 and Campbell's Concepts on lateral repair for chronic instability.