Treatment of Symptomatic Subfibular Ossicle by Excision and Modified Broström Procedure for Skeletally Immature Patients

Abstract

Background: Ossicle resection combined with ligament repair using the modified Broström procedure (MBP) is generally associated with favorable results in adults with symptomatic subfibular ossicles; however, the surgical results of this approach in skeletally immature patients remain unclear. The purpose of this study was to investigate the midterm clinical outcomes and radiographic outcomes including leg length and physeal growth of skeletally immature patients after this procedure. Methods: Twenty-six consecutive skeletally immature patients who underwent ossicle resection combined with the MBP were retrospectively evaluated. Clinical scores were evaluated using the visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Karlsson-Peterson score, and Tegner score. The talocrural angle, fibular length on radiographs, and tape-measured leg length between the 2 ankles were also measured at the final follow-up. Time of return to sports and postoperative complications were also evaluated. Results: Fourteen girls (53.8%) and 12 boys (46.2%) had surgery at a mean age of 12.7±2.4 years. Mean postoperative follow-up time was 40.0±10.8 months. Mean VAS pain score improved from 4.1 preoperatively to 0.5 at final follow-up ( P < .05). Mean AOFAS score, Karlsson score, and Tegner score all improved from 62.0, 54.0, and 2.8 preoperatively to 95.5, 94.0, and 5.4 ( P < .05), respectively, at final follow-up. Median time of return to sports was 17.0 weeks. Mean talocrural angle, fibular length, and tape-measured leg length of the injured ankle were not significantly different from those of the contra-side at the final follow-up. All patients were satisfied with the results; repeat ligamentous injury occurred in 2 patients (7.7%). We had no cases of wound infection, nerve injury, compartment syndrome, or any other complications. Conclusion: Ossicle resection combined with the MBP performed in skeletally immature patients with symptomatic subfibular ossicles resulted in improved clinical outcomes without disruption of fibular physeal growth by an average of 3.3-year follow-up. Level of Evidence: Level IV, case series.

Avulsion fracture is associated with more pain after anatomic repair procedure for ATFL injury at the talar side

“…The reason for the low morbidity rate was reported to be that the bone cortex at the talar insertion of the ATFL might be denser than that at the fibular insertion, and ligament fibre at the talar side might withstand greater tension and disperse the stress caused by the sudden ankle sprain [21]. Ligament insertion rupture may be combined with an avulsion fracture [27, 34]. An unhealed avulsion fracture is partially or completely embedded by fibres from the talar end of the ATFL, forming a pseudoarticulation with the distal fibula, which is usually surrounded by inflammatory soft‐tissue hyperplasia, leading to persistent pain or CAI and requiring surgical intervention [15].…”

“…In patients with CAI, the most commonly injured ligament is the anterior talofibular ligament (ATFL) [24], which often presents as ligament rupture, localized hyperintensity or scarring on magnetic resonance imaging (MRI). Occasionally, ossicles developed from chronic avulsion fractures at the fibular or talar side of the ATFL [27, 34], may be observed at the anterolateral side of the ankle joint [3, 19, 27].…”