Modified Brostrom Split Evans Procedure

In 1953, Evans36 described a biotenodesis procedure in which the peroneus brevis tendon is released at the musculotendinous junction, rerouted through the fibula, and then reattached to its proximal stump. This procedure was later modified by suturing the tendon back to itself instead of reattaching it to the proximal stump.37 In 1999, Girard et al38 reported on their results of the modified Brostrom-Evans procedure, a procedure that augments the Brostrom reconstruction with the addition of the anterior third of the peroneus brevis (Figs. 66-3 and 66-4). This procedure adds static restraint without a significant sacrifice of dynamic peroneal restraint. The authors believe that the modified Brostrom-split Evans has a role in revision surgery, obese individuals, heavy athletes (e.g., football lineman), laborers, and in patients with generalized ligamentous laxity. It is also our procedure of choice in patients with suspected combined instability patterns. Girard et al38 reported results in 21 patients at an average follow-up of approximately 2.5 years, finding that when compared to the uninjured contralateral side, there was no

Intermediate dorsal Cutaneous nerve

Evans Procedure

Figure 66-2 Modified Brostrom-Gould anatomic lateral ankle ligament reconstruction. A, Sensory nerve branches shown in relationship to the anterior incision. B, Midsubstance tears of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). C, Modified Brostrom repair with imbrication of the ATFL and CFL. Continued

Figure 66-2 Modified Brostrom-Gould anatomic lateral ankle ligament reconstruction. A, Sensory nerve branches shown in relationship to the anterior incision. B, Midsubstance tears of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). C, Modified Brostrom repair with imbrication of the ATFL and CFL. Continued

Modified Brostrom Gould
Extensor retinaculum

Figure 66-2—Cont'd D, Gould modification with interior extensor retinaculum-reinforcing repair.

significant difference in ankle plantarflexion or dorsiflexion and no significant loss of peroneal strength. They did report a significant loss of inversion.

The surgical technique for the modified Brostrom-split Evans involves a posterior curvilinear incision extending from 4 to 5 cm proximal to the tip of the lateral malleolus along the course of the peroneal tendons to a point approximately 2 cm proximal to the base of the fifth metatarsal. The skin flaps are then elevated to expose the anterolateral ankle capsule, the anterior distal fibula, and the peroneal tendons with care to avoid damage to branches of the superficial peroneal and sural nerves. The modified Brostrom portion of the procedure is carried out in identical fashion as described in the previous section with the sutures placed in the ATFL and CFL but not immediately tied. The peroneus brevis tendon is then exposed proximally and distally while maintaining the superficial peroneal retinaculum. The anterior one third of the peroneus brevis tendon is isolated distally and, using a no. 2 nylon suture, split from this distal point

Evans Procedure

Figure 66-3 Modified Brostrom-split Evans procedure. The end-to-end (shortening with imbrication) Brostrom repair of the anterior talofibular ligament and calcaneofibular ligament is performed with nonabsorbable suture. The anterior one third of the split peroneus brevis is then rerouted through the fibula and secured with either sutures at entrance and exit with suture (shown) or with a biotenodesis screw. (From Girard I? Anderson RB, Davis WH, et al: Clinical evaluation of the modified Brostrom-Evans procedure to restore ankle stability. Foot Ankle Int 1999;20:246-252.)

Figure 66-3 Modified Brostrom-split Evans procedure. The end-to-end (shortening with imbrication) Brostrom repair of the anterior talofibular ligament and calcaneofibular ligament is performed with nonabsorbable suture. The anterior one third of the split peroneus brevis is then rerouted through the fibula and secured with either sutures at entrance and exit with suture (shown) or with a biotenodesis screw. (From Girard I? Anderson RB, Davis WH, et al: Clinical evaluation of the modified Brostrom-Evans procedure to restore ankle stability. Foot Ankle Int 1999;20:246-252.)

Figure 66-4 The Gould et al35 modification augments the modified Brostrom-split Evans with the advancement of the extensor retinaculum to the distal fibula. This reinforces the repair, limits inversion, and helps to correct the subtalar component of instability. (Girard I? Anderson RB, Davis WH, et al: Clinical evaluation of the modified Brostrom-Evans procedure to restore ankle stability. Foot Ankle Int 1999;20:246-252.)

Rights were not granted to include this figure in electronic media Please refer to the printed publication.

to its musculotendinous junction. The anterior one third is then transected proximally and brought into the distal aspect of the wound. Next, a drill hole is made in the tip of the lateral malle-olus lateral to the articular surface between the insertions of the ATFL and CFL. The drill hole is directed posteriorly and prox-imally exiting approximately 2.5 cm proximal to the fibular tip. The split portion of the peroneus brevis is passed through the tunnel in a distal-to-proximal direction. Then the sutures of the CFL and ATFL are secured in the manner as described in the modified Brostrom. The peroneal transfer is tensioned with the foot in mild plantarflexion and eversion and secured either with a biotenodesis screw or sutures at its entrance and exit sites in the fibula.

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Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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