Arthroscopic modified Broström operation versus open reconstruction with local periosteal flap in chronic ankle instability

Arthroscopic modified Broström may improve function while anatomic reconstructions could enhance stability for chronic lateral ankle instability: A network meta-analysis

PURPOSE

The purpose of this systematic review and network meta-analysis was to compare the efficacy of different surgical treatments, including open and arthroscopic modified Broström procedures (MB), anatomical reconstructions, and suture tape augmentations (STA), for chronic lateral ankle instability (CLAI).

METHODS

We conducted a systematic search for comparative studies that included adult patients with CLAI who underwent open MB, arthroscopic MB, reconstruction with autografts or allografts, and STA. We used a random-effects model to present the NMA results, with mean differences and 95 % confidence intervals (CI) for continuous measures and relative ratios with 95 % CI for dichotomous variables. Surface under the cumulative ranking curve analysis (SUCRA) was used for treatment ranking.

RESULTS

The results, based on surface under the cumulative ranking curve analysis, showed that arthroscopic MB likely improves functional outcomes the most as measured by change in American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores. Anatomical graft reconstructions with allografts or autografts demonstrated greater reduction in anterior talar translation (ATT) and talar tilt angle (TTA). Arthroscopic MB and STA were associated with fewer complications.

CONCLUSIONS

Arthroscopic MB may be associated with better functional outcomes, while anatomical reconstructions appear to provide greater improvements in stability for CLAI. Additionally, arthroscopic techniques seem to have lower complication risks compared to open procedures. These potential differences in outcomes and risks between techniques could help guide surgical decision-making.

Clinical Outcomes and Return to Preinjury Sports After Anatomic Reconstruction With a Gracilis Autograft Versus the Modified Broström Procedure in Patients With Generalized Joint Laxity

Background

Generalized joint laxity (GJL) is a risk factor for inferior outcomes after the modified Broström procedure for chronic lateral ankle instability, while anatomic reconstruction with tendons is more inclined to be recommended. However, whether anatomic reconstruction could achieve better results than the modified Broström procedure in patients with GJL is unknown.

Purpose

To compare clinical outcomes and return to sports between anatomic reconstruction and the modified Broström procedure in patients with GJL.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients with GJL (Beighton score ≥4) who underwent either the modified Broström procedure or anatomic reconstruction with gracilis autografts between 2017 and 2020 were reviewed. Included were 19 patients who underwent anatomic reconstruction (reconstruction group) and 49 patients who underwent the modified Broström procedure (MBP group). Clinical outcomes were compared using the Foot and Ankle Outcome Score (FAOS) and the Karlsson score. The rates of return to preinjury level in high-demand sports, sprain recurrence, and range of motion between the 2 groups were also compared.

Results

The mean follow-up duration was 38.3 months in the reconstruction group and 43.7 months in the MBP group. The FAOS and Karlsson scores improved significantly after surgery in both groups (P < .001 for all), with the reconstruction group having significantly higher postoperative FAOS-Sports scores (87.9 ± 8.9 vs 80.5 ± 11.6; P = .015) and Karlsson scores (86.9 ± 6.1 vs 82 ± 8.4; P = .025) than the MBP group. The rate of return to preinjury high-demand sports was higher in the reconstruction group than in the MBP group (73.3% vs 38.9%; P = .034). The MBP group had a significantly higher rate of sprain recurrence (22.4% vs 0%; P = .027). More patients reported dorsiflexion restriction in the reconstruction group (n = 4; 21.1%) than in the MBP group (n = 1; 2%) (P = .019); nonetheless, there was no noticeable effect on daily life and sports.

Conclusion

Better clinical outcomes, less sprain recurrence, and a higher rate of return to preinjury high-demand sports were found after anatomic reconstruction with free tendons compared with the modified Broström procedure in patients with GJL. Anatomic tendon reconstruction can be recommended for such patients, especially those participating in high-demand sports.

Clinical outcomes of arthroscopic all-inside anterior talofibular ligament suture augmentation repair versus modified suture augmentation repair for chronic ankle instability patients

BACKGROUND

To compare the clinical efficacies of arthroscopic anterior talofibular ligament suture augmentation repair and modified suture augmentation repair in patients with chronic ankle instability (CAI).

METHODS

From October 2019 to August 2020, 100 patients with CAI were enrolled after propensity score matching analysis and observed for two years. Among them, 50 underwent modified suture augmentation repair and the other 50 underwent suture augmentation repair. The clinical efficacies of CAI treatments were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) clinical rating scale, visual analog scale (VAS), and anterior drawer test scores.

RESULTS

The postoperative AOFAS score of the modified suture augmentation repair group (83.8 ± 11.3) was significantly higher than that of the suture augmentation repair group (76.3 ± 11.3; P = 0.001). The VAS (P = 0.863) and anterior drawer test (P = 0.617) scores were not significantly different between the two treatment groups.

CONCLUSION

Both the modified suture augmentation repair and suture augmentation repair demonstrated good clinical efficacies. The AOFAS score of the modified suture augmentation repair group was superior to that of the conventional suture augmentation repair group. Thus, modified suture augmentation repair is a feasible and practical surgical technique for CAI treatment.

Both Open and Arthroscopic All-Inside Anatomic Reconstruction With Autologous Gracilis Tendon Restore Ankle Stability in Patients With Chronic Lateral Ankle Instability

PURPOSE

To compare the return to sports and short-term clinical outcomes between the arthroscopic all-inside and the open anatomic reconstruction with gracilis tendon autograft for chronic lateral ankle instability (CLAI) patients.

METHODS

From March 2018 to January 2020, 57 CLAI patients were prospectively included with arthroscopic all-inside anatomic reconstruction (n = 31) or open anatomic reconstruction (n = 26) with gracilis tendon autograft. The patients were evaluated before operation and at 3 months, 6 months, 12 months, and 24 months after surgery. The American Orthopaedic Foot and Ankle Society score (AOFAS), visual analog scale (VAS), and Karlsson-Peterson score were evaluated at each time point, and stress radiography with a Telos device was performed before surgery and at final follow-up. The time to return to full weightbearing walking, jogging, sports, and work, Tegner activity score, and complications were recorded and compared.

RESULTS

All the subjective scores significantly improved after surgery from the preoperative level. Compared with the open group, the arthroscopic group demonstrated significantly earlier return to full weightbearing walking (8.9 vs 11.7 weeks, P < .001), jogging (17.9 vs 20.9 weeks, P = .012), and recreational sports (22.4 vs 26.5 weeks, P = .001) with significantly better AOFAS score and Karlsson score at 3 to 6 months, and better VAS score at 6 months after surgery. The 2 groups demonstrated no significant difference in the surgical duration or surgical complications. No significant difference was found in the clinical scores or stress radiographic measurements at 24 months after surgery (P > .05).

CONCLUSION

Compared with the open procedure, the arthroscopic all-inside anatomic lateral ankle ligament reconstruction with autologous gracilis tendon could achieve earlier return to full weightbearing, jogging, and recreational sports with less pain and better ankle functional scores at 3 to 6 months after surgery. Similar favorable short-term clinical outcomes were achieved for both techniques at 2 years after surgery.

STUDY DESIGN

Level I, randomized controlled trial.

Surgical outcome of avulsion fractures of the distal fibula: a systematic literature review

PURPOSE

To provide a systematic overview of clinical and radiographic outcomes in patients who underwent surgical treatment of a painful avulsion fragment of the distal fibula also known as posttraumatic os subfibulare.

METHODS

A systematic literature search across two major sources (PubMed and Scopus) was performed. Twenty-seven studies were included and analyzed using the modified Coleman score to assess the methodologic quality.

RESULTS

The surgical treatment of symptomatic os subfibulare, with or without concomitant ankle instability, generally results in substantial improvement in clinical and radiographic outcomes with relative low complication rates. Clinical outcome measures may not be affected by the presence of ankle instability or by the fragment size. The methodological quality of analyzed studies was satisfactory.

CONCLUSION

Posttraumatic os subfibulare may result in chronic pain and ankle instability. If surgery is indicated, ankle instability should be concomitantly addressed when present. Based on available literature, satisfactory postoperative outcomes can be reliably expected following surgical treatment.

LEVEL OF EVIDENCE

Systematic Review of Level III and Level IV Studies, Level IV.

The lasso-loop technique is equivalent to the simple suture technique in arthroscopic anterior talofibular ligament repair

PURPOSE

To compare the clinical outcomes of the lasso-loop and simple suture techniques in arthroscopic anterior talofibular ligament (ATFL) repair for the treatment of chronic lateral ankle instability (CLAI).

METHODS

From 2018 to 2020, patients with CLAI who underwent arthroscopic ATFL repair using the lasso-loop or simple suture technique were matched 1:1 (arthroscopic lasso-loop [AL] group, n = 29; simple arthroscopic suture [AS] group, n = 29) based on age, sex, affected side, body mass index, and follow-up duration using propensity score matching and retrospectively evaluated. Karlsson score, visual analogue scale (VAS) score, Tegner score, anterior drawer test (ADT) results, complications, patient-reported satisfaction, and magnetic resonance (MR) re-evaluation findings of ATFL quality were used to describe the outcomes.

RESULTS

The patient characteristics or follow-up durations did not significantly differ between the two groups. The Karlsson score, VAS score, and Tegner score improved significantly in both groups after a mean follow-up duration of 29.6 ± 2.8 months. The postoperative clinical scores, ADT results, satisfaction rates, complication rates and MR re-evaluation findings were not significantly different between the two groups at the latest follow-up.

CONCLUSION

The lasso-loop technique was equivalent to the simple suture technique in arthroscopic ATFL repair for the treatment of CLAI after a minimum follow-up of 2 years, suggesting that the simple suture technique is sufficient for arthroscopic ATFL repair in most patients without the need to add a lasso loop.

LEVEL OF EVIDENCE

Level III.

Anatomic reconstruction using the autologous gracilis tendon achieved less sprain recurrence than the Broström-Gould procedure but delayed recovery in chronic lateral ankle instability

PURPOSE

To compare the return-to-activity and long-term clinical outcomes between anatomic lateral ligament reconstruction using the autologous gracilis tendon and modified Broström-Gould (MBG) procedure in chronic lateral ankle instability (CLAI). It was hypothesised that there was no difference between the two techniques.

METHODS

From 2013 to 2018, 30 CLAI patients with grade III joint instability confirmed by anterior drawer test underwent anatomic reconstruction of lateral ankle ligament with the autologous gracilis tendon (reconstruction group) in our institute. Another 30 patients undergoing MBG procedure (MBG group) were matched in a 1:1 ratio based on demographic parameters. The post-operative American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) pain score, Tegner activity score, Karlsson-Peterson score, surgical complications, return-to-activities and work were retrospectively evaluated and compared between the two groups.

RESULTS

All subjective scores significantly improved after the operation (all with p < 0.001) without difference between the two groups (all n.s.). The MBG group showed a significantly higher proportion of postoperative sprain recurrence than the reconstruction group (26.7% vs. 0, p = 0.002). The reconstruction group showed a significantly longer period to start walking with full weight-bearing (10.5 ± 6.9 vs. 7.0 ± 3.1 weeks, p = 0.015), jogging (17.1 ± 8.9 vs. 12.7 ± 6.9 weeks, p = 0.043) and return-to-work (13.5 ± 12.6 vs. 8.0 ± 4.7 weeks, p = 0.039) than the MBG group.

CONCLUSIONS

Both anatomic reconstruction using the autologous gracilis tendon and MBG procedure could equally achieved reliable long-term clinical outcomes and the tendon reconstruction showed a relatively lower incidence of postoperative sprain recurrence but delayed recovery to walking, jogging and return-to-work. The MBG procedure was still the first choice with rapid recovery but the tendon reconstruction was recommended for patients with higher strength demand.

LEVEL OF EVIDENCE

III.

Anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation for chronic lateral ankle instability with poor remnant quality: results and complications

PURPOSE

Treatment of chronic lateral ankle instability (CLAI) with poor remnant quality is challenging. The aim of the present study was to evaluate clinical results and complications of anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation in the treatment of such patients.

METHODS

One hundred and eight patients with CLAI, who were treated surgically using anatomic reconstruction with allograft tendon and suspensory fixation between April 2016 and January 2018 at our hospital, were retrospectively analysed. None of the patients had sufficient ligament remnants for the modified Broström procedure during the intraoperative evaluation. Eighteen patients were excluded. Seventeen patients were lost to follow-up and 73 patients completed the study. The mean duration of instability symptoms was 39.1 months (range, 6-480 months). The mean follow-up time was 57.5 months (range, 48-69 months). Clinical results were evaluated using the Karlsson scoring scale, American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) score, visual analogue scale (VAS), patients' subjective satisfaction, and incidence of complications. Mechanical stability was evaluated using the varus talar tilt angle (TTA) and anterior talar displacement (ATD).

RESULTS

The AOFAS-AH scores significantly improved from 67.7 ± 8.5 points to 89.8 ± 9.5 (p < 0.001). The Karlsson scoring scales evolved from 58.8 ± 16.5 to 88.4 ± 11.2 (p < 0.001). VAS scores significantly decreased from 2.9 ± 1.3 to 1.1 ± 1.0 (p < 0.001). On stress radiographs, TTA decreased from 15.1 ± 2.5 degrees to 5.8 ± 2.1 degrees (p < 0.001), whereas ATD reduced from 13.4 ± 2.9 mm to 5.7 ± 1.5 mm (p < 0.001). Patients' subjective satisfaction indicated 46 excellent, 20 good, 5 fair, and 2 bad results. Postoperatively, 15 cases (20.5%) did not achieve complete relief of discomfort or swelling, 9 cases (12.3%) experienced joint stiffness or decreased range of motion, and 6 cases (8.2%) had soft tissue irritation. Residual instability and reoperation are rare. Allograft rejection or wound infection was not observed.

CONCLUSION

For the CLAI patients with poor remnant quality, anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation is an effective procedure, while the top three complications in incidence were residual discomfort, joint stiffness, and soft tissue irritation.

LEVELS OF EVIDENCE

Level IV, retrospective case series.

High-stress distribution in the lateral region of the subtalar joint in the patient with chronic lateral ankle instability

PURPOSE

Chronic lateral ankle instability (CLAI) is associated with osteoarthritis (OA). However, the characteristics of patients with CLAI who progress to OA are not clear. Measurement of Hounsfield Unit (HU) value on computed tomography (CT) is reported to be useful to evaluate the stress distribution. We aimed to evaluate the stress distribution in the ankle and subtalar joints and factors enhancing it in patients with CLAI.

MATERIALS AND METHODS

Thirty-three ankles with CLAI (CLAI group) and 26 ankles without CLAI (control group) were included. A mean age of CLAI was 35.2 years and control was 30.3 years. Color map was created in the ankle and subtalar joint according to the HU values using three-dimensional CT to identify the region with high HU values, and HU values in those regions were measured using two-dimensional CT and compared between control and CLAI groups. In CLAI group, the relationships between HU values and ankle activity score (AAS), OA, talar tilting angle (TTA), cartilage injury were assessed.

RESULTS

The HU values in the anteromedial region of the talus and lateral region in the subtalar joint were higher than those in the control. In CLAI, patients with an AAS of ≧ 6, over 10° of TTA, cartilage injury, and OA changes in the medial gutter had significantly higher HU values in the lateral region of the subtalar joint than those with an AAS of ≦5, less than 10° of TTA without cartilage injury and OA change.

CONCLUSIONS

CLAI patients, especially in the patients with high activity level, large TTA, cartilage injury, and OA changes at the medial gutter, have high HU values in the lateral region of the subtalar joint, which suggests that disruption of the subtalar compensation toward OA will occur. For these patients, instability should be completely eliminated to prevent ankle OA.

LEVEL OF EVIDENCE

Level III, comparative series.

The ALR-RSI score is a valid and reproducible scale to assess psychological readiness before returning to sport after modified Broström-Gould procedure

PURPOSE

Psychological readiness scores have been developed to optimize the return to play in many sports-related injuries. The purpose of this study was to statistically validate the ankle ligament reconstruction-return to sport injury (ALR-RSI) scale after modified Broström-Gould (MBG) procedure.

METHODS

A similar version of the ACL-RSI scale with 12 items was adapted to quantify the psychological readiness to RTS after MBG and to describe construct validity, discriminant validity, feasibility, reliability and internal consistency of the scale, according to the COSMIN methodology. The term "knee" was replaced by "ankle". The AOFAS and Karlsson scores were used as references patient-related outcome measurements (PROMs).

RESULTS

A total of 71 patients were included. The ALR-RSI score after MBG procedure was highly (r > 0.5) correlated to the AOFAS and Karlsson scores, with a Pearson coefficient r = 0.69 [0.54-0.80] and 0.72 [0.53-0.82], respectively. The mean ALR-RSI score was significantly greater in the subgroup of 55 patients who resumed sports activity compared to those that no longer practiced sport: 61.9 (43.8-79.6) vs 43.4 (25.0-55.6), (p = 0.01). The test-retest showed an "excellent" reproducibility with a ρ intraclass correlation coefficient of 0.93 [0.86-0.96]. The Cronbach's alpha statistic was 0.95, attesting an "excellent" internal consistency between the 12 ALR-RSI items.

CONCLUSION

The ALR-RSI score is a valid and reproducible tool for the assessment of psychological readiness to RTS after an MBG procedure for the management of CLAI, in a young and active population. The ALR-RSI score may help to identify and counsel athletes on their ability to return to sport.

LEVEL OF EVIDENCE

III.

The L-shaped tunnel technique showed favourable outcomes similar to those of the Y-graft technique in anatomic lateral ankle ligament reconstruction

PURPOSE

To compare the mid- to long-term clinical and radiological outcomes of the confluent L-shaped tunnel technique with the Y-graft technique for anatomic lateral ankle ligament reconstruction.

METHODS

This retrospective study involved 41 patients who underwent lateral ankle ligament reconstruction between 2013 and 2018. Based on the tunnel direction and tendon fixation method at the fibula side, patients were divided into two groups, with 17 patients in the L-shaped tunnel group and 24 patients in the Y-graft group. The American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) pain score, Tegner score, and Karlsson score were evaluated and compared preoperatively and at follow-up. Anterior talar translation and talar tilt at stress radiographs, postoperative sprain recurrence, range of motion (ROM) restriction, sensory disturbance, etc., were also collected and compared.

RESULTS

The mean follow-up times were 72 and 42 months for the L-shaped group and Y-graft group, respectively. The median VAS pain score, Tegner score, AOFAS score, Karlsson score significantly improved from a preoperative level in both groups (all with p < 0.01). No significant difference was found between the two groups regarding the changes from preoperatively to postoperatively except for the VAS pain score reduction (1.58 ± 1.58 in the L-shaped group vs. 2.53 ± 1.29 in the Y-graft group, p = 0.035). The incidence of flexion-extension ROM restriction (≥ 5°) was significantly higher in the Y-graft group (41.2%) than in the L-shaped group (12.5%) (p = 0.035).

CONCLUSIONS

Both the confluent L-shaped tunnel technique and the Y-graft technique significantly improved symptoms, ankle function, and radiographic outcomes in patients with chronic lateral ankle instability (CLAI) at mid- to long-term follow-up. The confluent L-shaped tunnel technique resulted in lower rates of flexion-extension ROM restriction, while the Y-graft technique showed better VAS pain reduction. This result could provide further evidence for the surgical treatment of CLAI.

LEVEL OF EVIDENCE

III.

Absorbable suture anchor and knotless anchor techniques produced similar outcomes in arthroscopic anterior talofibular ligament repair

PURPOSE

The purpose of this study is to compare absorbable suture anchor with knotless anchor techniques for arthroscopic anterior talofibular ligament (ATFL) repair.

METHOD

A multicenter retrospective study was performed with 185 patients, who had undergone an arthroscopic ATFL repair procedure using absorbable suture anchor or knotless anchor between May 2017 and October 2019. The follow-up time was a minimum of 18 months. Karlsson-Peterson score, visual analogue scale (VAS), and Cumberland ankle instability tool (CAIT) were evaluated. The complications were also recorded.

RESULTS

One hundred and seven patients underwent one absorbable suture anchor repair procedure (Group A [A]), and the other seventy-eight patients underwent one knotless anchor repair procedure (Group B [B]). At the final follow-up, both Karlsson-Peterson score (A, pre 61.0 ± 8.0 vs post 93.5 ± 5.3, P < 0.001; B, pre 59.5 ± 8.2 vs post 92.4 ± 6.3, P < 0.001), VAS score (A, pre 5.0 ± 1.3 vs post 0.5 ± 0.7, P < 0.001; B, pre 5.5 ± 1.2 vs post 0.9 ± 1.0, P < 0.001), and CAIT score (A, pre 53.1 ± 12.0 vs post 93.1 ± 6.6, P < 0.001; B, pre 51.6 ± 12.0 vs post 93.1 ± 6.5, P < 0.001) improved significantly in both groups. There was no significant difference between the two groups regarding the Karlsson-Peterson score (A, pre 61.0 ± 8.0 vs B, pre 59.5 ± 8.2, n.s; A, post 93.5 ± 5.3 vs B, post 92.4 ± 6.3, n.s), CAIT score (A, pre 53.1 ± 12.0 vs B, pre 51.6 ± 12.0, n.s; A, post 93.1 ± 6.6 vs B, post 93.1 ± 6.5, n.s) and the change ranges of VAS (A, 4.5 ± 1.0 vs B, 4.6 ± 1.2, n.s). Anchor complications were easier to occur in Group B (0/107 vs 6/78, P = 0.007). Knot irritation slightly increased in Group A (10/107 vs 0/78, P = 0.006). No significant difference was found regarding total complication rates (A, 10/107 vs B, 6/78, n.s).

CONCLUSION

Absorbable suture anchor and knotless anchor for arthroscopic ATFL repair produced similar clinical outcomes. The ankle stability scores increased significantly in both groups. However, the knotless anchor has a higher risk to loosen, deviated direction or break, while the absorbable suture anchor still has a slim chance of knot irritation.

LEVEL OF EVIDENCE

III.