Anatomic Suture Anchor Versus the Brostrom Technique for Anterior Talofibular Ligament Repair A Biomechanical Comparison

Background: Despite the popularity of the Brostrom procedure for secondary repair of chronic lateral ankle instability, there have been no biomechanical studies reporting on the strength of this secondary repair method, whether using suture fixation or suture anchors. Hypothesis: The purpose of our study was to perform a biomechanical comparison of the ultimate load to failure and stiffness of the traditional Brostrom technique using only a suture repair compared with a suture anchor repair of the anterior talofibular ligament (ATFL) at time zero. We believed that fixation strength of the suture anchor repair would be closer to the strength of the native ligament and allow more aggressive rehabilitation. Study Design: Controlled laboratory study. Methods: Twenty-four fresh-frozen cadaveric ankles were randomly divided into 4 groups of 6 specimens. One group was an intact control group, and the other groups consisted of the traditional Brostrom and 2 suture anchor modifications (suture anchors in talus or fibula) of the Brostrom procedure. The specimens were loaded to failure to determine the strength and stiffness of each construct. Results: In load-to-failure testing, ultimate failure loads of the Brostrom (68.2 +/- 27.8 N; P = .013), suture anchor fibula (79.2 +/- 34.3 N; P = .037), and suture anchor talus (75.3 +/- 45.6 N; P = .027) repairs were significantly lower than that of the intact (160.9 +/- 72.2 N) ATFL group. Stiffness of the Brostrom (6.0 +/- 2.5 N/mm; P = .02), suture anchor fibula (6.8 N/mm +/- 2.7; P = .05), and suture anchor talus (6.6 N/mm +/- 4.0; P = .04) repairs were significantly lower than that of the intact (12.4 N/mm +/- 4.1 N/mm) ATFL group. The 3 repair groups were not significantly different from each other, but all 3 were substantially lower in strength and stiffness when compared to the intact ATFL. Conclusion: The use of suture anchors to repair the ATFL produces a repair that can withstand loads to failure similar to the suture-only Brostrom repair. However, all 3 repair groups were much weaker than the intact, uninjured ATFL. Clinical Relevance: Biomechanically, the results show that both suture anchor and direct suture repair of the ATFL provide similar strength and stiffness. Unfortunately, these methods provide less than half the strength and stiffness of the native ATFL at time zero. As a result, regardless of the repair method, it is necessary to sufficiently protect the repair to avoid premature failure.