Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-015-3631-7
ANKLE
Comparison of Broström technique, suture anchor repair,
and tape augmentation for reconstruction of the anterior
talofibular ligament
R. Schuh1 · E. Benca1 · M. Willegger1 · L. Hirtler2 · S. Zandieh3 · J. Holinka1 ·
R. Windhager1 Received: 22 September 2014 / Accepted: 29 April 2015
© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015
Abstract Purpose Recently, tape augmentation for Broström repair
has been introduced in order to improve the primary stability of the reconstructed anterior talofibular ligament
(ATFL). The biomechanical effect of tape augmentation
suture anchor (SA) repair is not known yet. The aim of the
present study was to compare construct stability of the traditional Broström (TB) repair compared with a stand alone
SA repair (SutureTak®, Arthrex) and SA repair combined
with tape augmentation (InternalBrace®, Arthrex) internal
brace (IB) of the ATFL.
Methods Eighteen fresh-frozen human anatomic lower
leg specimens were randomly assigned to three different
groups: TB group, SA group, and IB augmentation group.
In vivo torsion conditions in ankle sprain were carried out
quasi-statically (0.5°/s). Torque (Nm) required to resist as
well as the rotary displacement (°) of the load frame was
recorded. Intergroup differences for age, bone mineral density (BMD), angle at failure, and torque at failure were analysed using ANOVA.
Results In the TB group, ATFL reconstruction failed at an
angle of 24.1°, in the SA group failure occurred at 35.5°,
and in the IB group it failed at 46.9° (p = 0.02). Torque at
Electronic supplementary material The online version of this
article (doi:10.1007/s00167-015-3631-7) contains supplementary
material, which is available to authorized users.
* R. Schuh
[email protected]
1
Department of Orthopaedics, Medical University of Vienna,
Waehringer Guertel 18 – 20, 1090 Vienna, Austria
2
Center of Anatomy and Cellular Biology, Medical University
of Vienna, Vienna, Austria
3
Department of Radiology, Hanusch Hospital, Vienna, Austria
failure reached 5.7 Nm for the TB repair, 8.0 Nm for the
SA repair, and 11.2 Nm for the IB group (p = 0.04). There
was no correlation between angle at ATFL failure, torque at
failure, and BMD for the SA or IB groups.
Conclusion The present biomechanical study reveals statistically superior performance in terms of angle at failure
as well as failure torque for the IB group compared to the
other reconstruction methods. BMD did not influence the
construct stability in the SA repair groups.
Keywords Ankle lateral ligament · Broström · Suture
anchor · Tape augmentation · Bone mineral density
Introduction
Although many patients have good clinical outcomes after
nonoperative treatment of lateral ankle ligament sprains,
a significant number of patients experience chronic pain,
instability, loss of range of motion, and poor proprioception
[4, 19, 22, 27]. Many investigators reported a relationship
between chronic lateral ankle instability and the development of degenerative changes [5, 8, 10, 25, 26]. Therefore,
the latter frequently requires surgical intervention to repair
or to reconstruct the lateral ankle ligaments and to stabilize
the ankle mortise [2, 5].
In 1966, Broström described his anatomic repair of the
lateral ankle ligaments, specifically the anterior talofibular
ligament (ATFL) [1, 6, 9, 12]. Since then, there have been
many adaptations to the originally described procedure,
both anatomic and nonanatomic with varying degrees of
success in clinical routine, as reported in the literature [3, 5,
7, 8, 11, 13–16, 18, 20, 21, 29].
In vitro studies support the assumption that limited protected weight-bearing is necessary after ATFL ligament
13
Knee Surg Sports Traumatol Arthrosc
Table 1 Demographics and bone mineral density (BMD) of the certain specimens of the different groups
Group
Age mean (range), (yr)
Male/female (n)
Right/left (n)
BMD mean ± SD (g/cm2)
TB
SA
IB
77.5 (64–88)
81.8 (71–90)
77.1 (71–89)
2:4
4:2
3:3
2:4
3:3
5:1
0.54 ± 0.26
0.51 ± 0.22
0.61 ± 0.21
All specimens
78.8 (64–90)
9:9
10:8
0.55 ± 0.22
yr years, SD standard deviation, n number, TB traditional Broström group, SA Broström suture anchor repair, IB tape augmentation repair group
reconstruction in order to avoid ligament lengthening. It
has been shown that the reconstruction of the ATFL does
not restore the strength of the native ATFL even with suture
anchor repair or traditional Broström. Therefore, restrictions in post-operative rehabilitation are recommended and
early aggressive rehabilitation protocols should be omitted
[29].
Recently, tape augmentation for traditional Broström
repair has been described in order to improve the primary
stability of the reconstructed ATFL. However, to the best
of our knowledge, the stability of tape augmentation for
suture anchor repair has not been addressed in the past.
Also, the correlation of BMD and stability of suture anchor
repair with or without tape augmentation for lateral ankle
instability has not been examined.
Therefore, the aim of the present study was to perform a
biomechanical comparison of the ultimate torque and angle
at failure of the traditional Broström technique using a
suture-only repair compared to a standalone suture anchor
repair and suture anchor repair combined with tape augmentation (InternalBrace®, Arthrex Inc., Naples, FL, USA)
of the ATFL. Additionally, an assessment of failure mode
and influence of BMD on construct failure was carried out.
We hypothesized that tape augmentation would improve
construct stability and that the stability of anchor reconstruction is influenced by BMD.
Materials and methods
Specimens
Eighteen (18) fresh-frozen human anatomic lower leg
specimens (mean age 78.8 year; range 64–90 year) were
obtained for data collection (Table 1). The criteria for
exclusion in specimens were an age younger than 20 or
older than 90 years, any evidence of prior ankle injury by
direct inspection, any history of injury of the lower extremity or death due to cancer. Prior to the selection, BMD was
assessed for by dual X-ray absorptiometry (DEXA).
The final selection of the specimens was performed after
inspection of the ankle joint for intact ligaments, tendons,
13
and ankle mortise. The specimens were stored at −70 °C
and were thawed at room temperature for 24 h before use in
order to prevent possible change of mechanical properties
due to dehydration [30, 31]. In the following, specimens
were randomly assigned to three different groups for ATFL
reconstruction methods. Age distribution and BMD were
similar among the three groups. The specimens of the first
group of six served as the Broström suture anchor (SutureTak®, Arthrex Inc., Naples, FL, USA) repair group (SA),
six served as the traditional Broström group (TB), and six
served as the suture anchor procedure (SutureTak®, Arthrex
Inc., Naples, FL, USA) combined with tape augmentation (InternalBrace®, Arthrex Inc., Naples, FL, USA) (IB)
(Fig. 1a–c). All dissections and repairs were performed by
a single experienced orthopaedic surgeon.
Surgical procedure
A J-shaped incision was performed just anterior to the fibula to allow easy exposure to the anterolateral capsule and
ATFL and the calcaneofibular ligament (CFL). The incision
extended from the distal tip of the fibula along its anterior
margin proximally to the level of the ankle mortise. The
dissection was taken down to the fibular periosteum. Subsequently, the joint capsule was incised in line with the skin
incision and just distal to the leading edge of the fibula. The
ATFL and CFL were inspected. If no prior injury of these
structures was evident, they were selected for further investigations. The lateral shoulder of the talus was inspected as
well. Then, a curved haemostat was placed within the lateral ankle joint and passed under the lateral capsule and the
ATFL, exiting just anterior to the peroneal tendon sheath.
The capsuloligamentous tissue from the interval between
the anteroinferior tibiofibular ligament insertion and the
peroneal tendon sheath near the distal tip of the fibula was
divided to section the ATFL with use of a scalpel. According to Waldrop et al. [29], the ATFL was divided in midsubstance for the TB technique, near the fibular insertion for
the suture anchor group (SA), and near the talar neck insertion for the suture anchor tape augmentation group (IB). An
anterior drawer test was performed in order to confirm the
creation of anterior instability of the ankle.
Knee Surg Sports Traumatol Arthrosc
braided polyethylene/polyester multifilament sutures
(FiberWire®, Arthrex Inc., Naples, FL, USA) were used to
suture the ATFL ligament in a pants-over-vest fashion in an
imbricated position. The foot was held in a slightly plantar
flexed and everted position with a bump placed under the
tibia, allowing the foot to remain under the ankle mortise.
The anterior drawer test was applied to each specimen to
verify adequate repair and stability of the ankle mortise.
Suture anchor technique (SA)
When SA repair was used, the ATFL was identified and
divided near its fibular insertion. A single suture anchor
(3 × 10 mm Bio-SutureTak®, Arthrex, Inc., Naples, FL,
USA) was placed at the centre of ATFL origin on the distal
fibula, 11 mm proximal to the distal tip of the fibula. The
anchor was loaded with two No. 0 nonabsorbable, continuous braided polyethylene/polyester multifilament sutures
(FiberWire®, Arthrex Inc., Naples, FL, USA). The ligament
repair was performed by bringing the sutures from deep
to superficial in a horizontal mattress pattern. The sutures
were tied over the top. In the following, an anterior drawer
test was performed in order to clinically assess the stability
of the repair.
Tape augmentation technique (IB)
Fig. 1 Schematic drawings of different methods of ATFL reconstruction. Traditional Broström (TB) (a), suture anchor repair (3 × 10 mm
Bio-SutureTak, Arthrex, Inc., Naples, FL) (SA) (b), and suture anchor
repair combined with tape augmentation (InternalBrace®, Arthrex
Inc., Naples, FL, USA) (c)
Traditional Broström technique (TB)
The technique was performed according to the anatomic
repair technique originally described by Broström. After
the ATFL was identified and a curved haemostat was
placed, it was inspected for tissue quality. It was thereafter
divided at its midsubstance in order to allow a traditional
Broström repair. Two No. 0 nonabsorbable, continuous
The InternalBrace® (Arthrex Inc., Naples, FL, USA) was
designed to augment a traditional Broström procedure utilizing BioComposite SwiveLocks® (Arthrex Inc., Naples,
FL, USA) and FiberTape® (Arthrex Inc., Naples, FL,
USA).
After the standard Broström suture anchor repair technique was applied, the InternalBrace® was applied superficially, 1.5 cm proximal from the tip of the distal fibula.
A hole was drilled with the 2.7-mm drill in the fibula,
angled slightly proximally, in line with the lateral border
of the foot. Subsequently, the hole was taped with a 3.5mm tape for at least two turns to breach the fibular cortex.
The 3.5-mm SwiveLock® loaded with FiberTape® was
placed into the fibular drill hole. The green paddle on the
screwdriver was held stationary while turning the driver
clockwise. The black line on the driver was buried into the
bone. The 3.4-mm drill was drilled into the lateral aspect of
the talus in line with the superior ATFL directed 45° posteromedially with respect to the lateral border of the foot.
The talar tunnel was taped down to the laser line on the
4.75-mm SwiveLock® Tape found in the reusable instrument set. Range of motion was assessed prior the insertion
of the second anchor. Both limbs of the FiberTape® were
passed through the eyelet of the 4.75-mm SwiveLock®, and
the anchor was inserted. To avoid over-tensioning, a small
curved haemostat was placed between FiberTape® and talus
13
Fig. 2 Biomechanical test set-up. Lower leg specimen (1) mounted
into the testing frame (2) using Wood’s metal and steel cups (3). A
Kirschner wire (4) locks tibiofibular mobilization. Steinmann pin (5)
is passed through the calcaneus and fixed into the mounting platform
(6)
while inserting SwiveLock®. Again, construct stability was
assessed clinically by an anterior drawer test.
Mechanical testing
An experimental set-up, designed to simulate in vivo ankle
sprain conditions, was used [30, 31]. The lower leg of all
specimens was potted in Wood’s metal in 40-mm-diameter,
custom-build steel cup, which allows mounting in the servo
hydraulic test frame 858 Mini Bionix (MTS Systems Corporation, Eden Prairie, MN, USA) (Fig. 2). A fixed laser
beam was used to position the specimen with their mechanical tibial axis coinciding with the rotational axis of the
testing machine. Each specimen was attached to a custom
testing apparatus in 20° of plantar flexion and 15° of internal rotation [3].
Tibiofibular destabilization was prevented by drilling and securing the fibula on the outside of the cup with
a 2.5-mm Kirschner wire (Fig. 2). A mounting platform,
specially designed to simulate ankle sprain conditions,
allows a calcaneal fixation of the ankle joint with a 4.5-mm
13
Knee Surg Sports Traumatol Arthrosc
Steinmann pin, which is then inserted into a pathway of the
platform on one side and secured into a guide block on the
other side [30, 31]. The pin was passed behind the longitudinal axis of the tibia and secured with methyl methacrylate
cement against relative movement to minimize the tunnel
enlargement in the calcaneus and resulting measurement
errors. The pin fixation in the calcaneus is of great importance for the evaluation of biomechanics of ligamentous
structures and their stabilizing role in the talocalcaneal as
well as in the talocrural joint. The platform allows an exact
positioning and screw locking system within the load frame
(Fig. 2).
In vivo torsion conditions in ankle sprain by 858 Mini
Bionix were carried out quasi-statically (0.5°/s) from 0° to
90° of internal rotation in line with the anatomic axis of the
tibia against the calcaneus. The maximum of internal rotation of 90° is not a realistic condition in an ankle sprain,
but chosen to ensure a rupture of reconstructed ligamentous
structures. The torque (Nm) required to resist the internal
rotation, as well as the corresponding rotary displacement
(°) of the load frame was recorded at a sampling frequency
of 20 Hz as a measurement unit for rotator instability in the
joint. The procedure was stopped at the maximum 90° of
internal rotation. The measurement transducer for the angular displacement and the torque are integrated into the 858
Mini Bionix testing system. The uncertainty in measurement for torque and angular displacement of the system is
1 %.
The torque and inversion angle at failure were recorded
at the failure time determined from the video recordings.
Failure was typically associated with a sharp drop in
torque over time. Two authors (E.B. and R.S.) independently reviewed all video recordings in a blinded manner.
For each specimen, the mode of failure was recorded with
regard to knot failure, suture breakage, pull-out, or tissue
failure [3].
Statistical analysis
All analyses were performed using SPSS 21.0 for Mac OS
X (SPSS Inc, Chicago, IL, USA), and the level of significance was set at 0.05.
Intergroup differences for age, BMD, failure angle, and
failure torque were analysed using ANOVA.
A post hoc power analysis was performed with G*Power
3.1. for MAC OS X (http://www.gpower.hhu.de).
For ANOVAs that demonstrated a statistically significant
difference, a post hoc Tukey honest significant difference
test was conducted to assess the location of the means that
were statistically significant between the groups. Pearson’s
product-moment correlation coefficient was calculated in
order to investigate the relationship between angle at failure, torque at failure, and BMD (Fig. 3).
Knee Surg Sports Traumatol Arthrosc
Fig. 3 Talar screw pull-out of the tape augmentation construct after
biomechanical testing. The most common mode of failure in the IB
group was a ligament–suture interface rupture in combination with a
talar screw pull-out (four out of six specimens)
Results
There was a statistically significant difference in angle at failure as well as in torque at failure for the different constructs.
In the TB group, ATFL reconstruction failed at an angle of
24° ± 9°, in the SA group failure occurred at 36° ± 11°, and
in the IB group it failed at 47° ± 17° (p = 0.02) (Fig. 4a).
Torque at failure reached 5.7 ± 2.6 Nm for the TB
repair, 8.0 ± 4.2 Nm for the SA repair, and 11.2 ± 3.7 Nm
for the IB group (p = 0.04) (Fig. 4b).
All constructs failed due to ligament–suture interface
rupture in the TB and SA group, respectively (see additional material). Also, in the IB group, this was part of
the most common failure mechanism. Additionally, there
occurred screw pull-out at the talus in four constructs and
screw pull-out at the fibula in two constructs (Fig. 3b).
Mean BMD reached 0.51 ± 0.22 g/cm2 for the SA group,
0.54 ± 0.26 g/cm2 for the TB group, and 0.57 ± 0.22 g/cm2
for the IB group. The difference was not statistically significant (n.s.). There was no correlation between angle at ATFL
failure or torque at failure, respectively, for the groups where
suture anchors or interference screws have been used (SA,
IB). Also, no statistically significant correlation was found
in subgroup analysis of the IB construct for specimens with
either a talar screw pull-out or a fibular screw pull-out.
Discussion
The most important findings were biomechanically superior results in terms of construct stability for suture anchor
Fig.  4 a, b Angle and torque at failure for different methods of ATFL
reconstruction. The error bars indicate the standard deviation. The
asterisk (*) highlights statistically significant differences (p < 0.05)
fixation combined with tape augmentation compared to the
other reconstruction methods. BMD did not influence the
construct stability in the suture anchor repair groups.
Results of the present study reveal that tape augmentation for Broström repair with suture anchor provides a 94 %
higher angle at construct failure than traditional Broström
repair and a 47 % higher angle than Broström repair with
suture anchor. Also, there is a 95 % higher torque at failure
in the tape augmentation construct compared to Broström
repair and a 54 % higher torque at failure compared to the
suture anchor repair. A recent study of Viens et al. [28]
showed an increase in mean load to failure and in stiffness
of 50 % for tape augmentation compared to native ATFL.
The authors did not find statistically significant differences
for these parameters between tape augmentation combined
with traditional Broström repair and the native ATFL. However, they did not evaluate the suture anchor repair that was
to provide biomechanically superior stability to traditional
Broström repair but inferior to the native ATFL. Therefore,
they concluded for the necessity of further studies. Due to
the relatively unstable construct of isolated suture anchor
repair, Waldrop et al. [29] illustrated the importance of
13
protection from excessive stress for these repairs during the
early post-operative rehabilitation phase.
Early range of motion was found effective for the rehabilitation after ligament repair [13, 24]. Therefore, an
aggressive rehabilitation protocol should be applied to the
patient, especially in the athletic population. Kirk et al.
[17] demonstrated in a biomechanical study lengthening of
20 % in the ATFL after Broström repair when unprotected
mobilization has been performed. Elongation of ligaments
during early mobilization after reconstruction may be associated with joint laxity and decreased stability [23]. This
indicates the need of a construct that provides higher initial
stability than the traditional Broström repair or the suture
anchor modification. In the clinical situation, the augmentation device may allow for an early rehabilitation program
which is of special importance for patients with a high
activity profile. Also, it may improve construct stability in
patients with high external forces due to misalignment of
the hindfoot (e.g. cavovarus).
There was no statistically significant difference between
the groups in BMD. For the groups, in which anchor repair
was used (IB, SA), we did not identify statistically significant correlation between BMD and angle or torque at failure. This might be due to the mode of failure that was ligament–suture interface failure in the majority of cases.
In the present study, none of the isolated suture anchor
repairs failed due to anchor pull-out. The major mode of
failure in both, suture anchor and traditional Broström
repairs, represented ligament–suture interface rupture
which indicates that at time zero augmentation might be
helpful in order to avoid this type of failure. This corresponds to the results of others [3, 29].
There are several limitations associated with this study.
First, the number of specimens is relatively low. However,
this is a common problem in biomechanical analysis on lateral ligament repair and power analysis revealed sufficient
sample size in order to generate statistically significant
results [3, 5, 28, 30]. Also, with an average of 78.8 years,
donors’ age is relatively high and it might not reflect the
age of patients who typically experience lateral ankle
sprain resulting in chronic instability. The mean age corresponds to the values in other studies focusing on this topic
[3, 5, 28, 30]. Also, BMD that might be affected by age
did not differ between the groups. The testing mechanism
included the scenario of inversion trauma and therefore the
application of rotational force in slight plantar flexion. This
represents a situation of maximum load under unprotected
conditions and not the forces that might occur in protected
weight-bearing and dorsi-plantar flexion exercises. However, in order to evaluate construct stability, we decided to
apply stress in a manner that the ATFL construct is maximally stressed.
13
Knee Surg Sports Traumatol Arthrosc
Conclusion
The results of the present study indicate that tape augmentation improves the stability of suture anchor repair of the
ATFL. Since the major mode of failure represents ligament–suture interface rupture, the augmentation seems to
protect against this mechanism.
Acknowledgments The study was approved by the Ethics Committee of the Medical University of Vienna (EK 1895/2013).
References
1. Amis AA, de Leeuw PAJ, van Dijk CN (2010) Surgical anatomy
of the foot and ankle. Knee Surg Sports Traumatol Arthrosc
18:555–556
2. Baumhauer JF, O’Brien T (2002) Surgical considerations in the
treatment of ankle instability. J Athl Train 37:458–462
3. Brown CA, Hurwit D, Behn A, Hunt KJ (2014) Biomechanical
comparison of an all-soft suture anchor with a modified Broström-Gould suture repair for lateral ligament reconstruction.
Am J Sports Med 42:417–422
4. Caputo AM, Lee JY, Spritzer CE, Easley ME, DeOrio JK, Nunley
JA, DeFrate LE (2009) In vivo kinematics of the tibiotalar joint
after lateral ankle instability. Am J Sports Med 37:2241–2248
5. Giza E, Nathe R, Nathe T, Anderson M, Campanelli V (2012)
Strength of bone tunnel versus suture anchor and push-lock construct in Broström repair. Am J Sports Med 40:1419–1423
6. Golanó P, Vega J, de Leeuw PAJ, Malagelada F, Manzanares
MC, Götzens V, van Dijk CN (2010) Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc
18:557–569
7. Gould N, Seligson D, Gassman J (1980) Early and late repair of
lateral ligament of the ankle. Foot Ankle 1:84–89
8. Harrington KD (1979) Degenerative arthritis of the ankle secondary to long-standing lateral ligament instability. J Bone Joint
Surg Am 61:354–361
9. Hazratwala K, Best A, Kopplin M, Giza E, Sullivan M (2005)
A radiographic investigation to determine the safety of suture
anchor systems for pediatric modified Broström ankle ligament
reconstruction. Am J Sports Med 33:435–438
10. Hirose K, Murakami G, Minowa T, Kura H, Yamashita T (2004)
Lateral ligament injury of the ankle and associated articular cartilage degeneration in the talocrural joint: anatomic study using
elderly cadavers. J Orthop Sci 9:37–43
11. Jung H-G, Kim T-H, Park J-Y, Bae E-J (2012) Anatomic reconstruction of the anterior talofibular and calcaneofibular ligaments
using a semitendinosus tendon allograft and interference screws.
Knee Surg Sports Traumatol Arthrosc 20:1432–1437
12. Kaplan LD, Jost PW, Honkamp N, Norwig J, West R, Bradley JP
(2011) Incidence and variance of foot and ankle injuries in elite
college football players. Am J Orthop 40:40–44
13. Karlsson J, Rudholm O, Bergsten T, Faxén E, Styf J (1995) Early
range of motion training after ligament reconstruction of the
ankle joint. Knee Surg Sports Traumatol Arthrosc 3:173–177
14. Karlsson J, Lundin O, Lind K, Styf J (1999) Early mobilization
versus immobilization after ankle ligament stabilization. Scand J
Med Sci Sports 9:299–303
15. Kennedy JG, Smyth NA, Fansa AM, Murawski CD (2012) Anatomic lateral ligament reconstruction in the ankle: a hybrid technique in the athletic population. Am J Sports Med 40:2309–2317
Knee Surg Sports Traumatol Arthrosc
16. Kim HN, Jeon JY, Dong Q, Noh KC, Chung KJ, Kim HK,
Hwang JH, Park YW (2014) Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/
s00167-014-3072-8
17. Kirk KL, Campbell JT, Guyton GP, Parks BG, Schon LC (2008)
ATFL elongation after Brostrom procedure: a biomechanical
investigation. Foot Ankle Int 29:1126–1130
18. Krips R, Brandsson S, Swensson C, van Dijk CN, Karlsson J
(2002) Anatomical reconstruction and Evans tenodesis of the
lateral ligaments of the ankle. Clinical and radiological findings after follow-up for 15 to 30 years. J Bone Joint Surg Br
84:232–236
19. Laver L, Carmont MR, McConkey MO, Palmanovich E, Yaacobi
E, Mann G, Nyska M, Kots E, Mei-Dan O (2014) Plasma rich
in growth factors (PRGF) as a treatment for high ankle sprain in
elite athletes: a randomized control trial. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-014-3119-x
20. Lee KT, Kim ES, Kim YH, Ryu JS, Rhyu IJ, Lee YK (2014)
All-inside arthroscopic modified Broström operation for chronic
ankle instability: a biomechanical study. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-014-3159-2
21. Lee KT, Park YU, Kim JS, Kim JB, Kim KC, Kang SK (2011)
Long-term results after modified Brostrom procedure without calcaneofibular ligament reconstruction. Foot Ankle Int
32:153–157
22. Miyamoto W, Takao M, Matsushita T (2013) Anterior fibrous
bundle: a cause of residual pain and restrictive plantar flexion
following ankle sprain. Knee Surg Sports Traumatol Arthrosc
21:1385–1389
23. Omar M, Petri M, Dratzidis A, El Nehmer S, Hurschler C,
Krettek C, Jagodzinski M, Ettinger M (2014) Biomechanical
comparison of fixation techniques for medial collateral ligament
anatomical augmented repair. Knee Surg Sports Traumatol
Arthrosc. doi:10.1007/s00167-014-3326-5
24. Safran MR, Zachazewski JE, Benedetti RS, Bartolozzi AR, Mandelbaum R (1999) Lateral ankle sprains: a comprehensive review
part 2: treatment and rehabilitation with an emphasis on the athlete. Med Sci Sports Exerc 31:438–447
25. Valderrabano V, Hintermann B, Horisberger M, Fung TS (2006)
Ligamentous posttraumatic ankle osteoarthritis. Am J Sports
Med 34:612–620
26. Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B (2008) Etiology of ankle osteoarthritis. Clin Orthop
Relat Res 467:1800–1806
27. van den Bekerom MPJ, Kerkhoffs GMMJ, McCollum GA,
Calder JDF, van Dijk CN (2013) Management of acute lateral
ankle ligament injury in the athlete. Knee Surg Sports Traumatol
Arthrosc 21:1390–1395
28. Viens NA, Wijdicks CA, Campbell KJ, Laprade RF, Clanton
TO (2014) Anterior talofibular ligament ruptures, part 1: biomechanical comparison of augmented Broström repair techniques
with the intact anterior talofibular ligament. Am J Sports Med
42:405–411
29. Waldrop NE, Wijdicks CA, Jansson KS, Laprade RF, Clanton
TO (2012) Anatomic suture anchor versus the Broström technique for anterior talofibular ligament repair: a biomechanical
comparison. Am J Sports Med 40:2590–2596
30. Ziai P, Benca E, Skrbensky GV, Wenzel F, Auffarth A, Krpo
S, Windhager R, Buchhorn T (2013) The role of the medial
ligaments in lateral stabilization of the ankle joint: an in vitro
study. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/
s00167-013-2708-4
31. Ziai P, Benca E, von Skrbensky G, Graf A (2013) The role of the
peroneal tendons in passive stabilisation of the ankle joint: an in
vitro study. Knee Surg Sports Traumatol Arthrosc 21:1404–1408
13