Lateral augmentation reconstruction system versus modified Brostrom-Gould procedure: A meta-analysis of RCTs

Arthroscopic Anterior Talofibular Ligament Repair Combined With All-Inside Suture Tape Augmentation for Treatment of Chronic Lateral Ankle Instability With Generalized Joint Laxity

BACKGROUND

To analyze the feasibility and clinical results of the modified Broström operation (MBO) combined with suture tape augmentation under arthroscopy for chronic lateral ankle instability (CLAI) in patients with generalized joint laxity (GJL).

METHODS

From October 2019 to October 2021, a total of 111 patients (111 ankles) treated with MBO combined with suture tape augmentation under arthroscope were retrospectively divided into a GJL group (29 patients) and a control group (82 patients). Mechanical stability of the affected ankle joint was evaluated radiographically preoperatively, at 6 months postoperatively, and the last follow-up. Complications and surgical failures, as well as visual analog scale (VAS) score, the Foot and Ankle Ability Measure (FAAM), and the Karlsson score were also recorded. All statistical analyses were completed using SPSS 20.0.

RESULTS

The average follow-up time was 21.7 ± 5.2 months for the GJL group, and 20.9 ± 5.3 months for the control group. Pain and symptoms in both groups were effectively relieved by the procedure reflected by decreased VAS scores, improved FAAM and Karlsson scores at 6 months postoperatively, and the final follow-up (P < .05). Preoperative talar tilt angle and anterior talar translation were significantly greater in the GJL group than those in the control group (P < .05). Postoperatively, both talar tilt angle and anterior talar translation were reduced in both groups at 6 months postoperatively and the last follow-up (P < .05), and we found no significant difference between the two groups (P > .05). Furthermore, we found no significant difference in VAS, FAAM, and Karlsson scores between the 2 groups 6 months postoperatively and at the last follow-up.

CONCLUSION

Arthroscopic MBO combined with suture tape augmentation is a reliable procedure for treating CLAI with GJL. At short-term follow-up, we found that the GJL group achieved an equivalent level of stability compared with the control group.

Treatment and prevention of chronic ankle instability: An umbrella review of meta-analyses

BACKGROUND

Chronic ankle instability (CAI) is a common and highly disabling condition. Although several studies have evaluated and analyzed prevention and treatment strategies for CAI, an unbiased and systematic synthesis of evidence is required to provide the most powerful and comprehensive evidence-based measures for the its prevention and treatment of CAI. This study aimed to synthesize evidence from the existing literature addressing the treatment and prevention of CAI.

METHODS

The PubMed, Embase, Cochrane, and Web of Science databases were systematically searched for relevant studies from inception to December 12, 2023. Data on effect sizes and corresponding 95 % confidence intervals for selected intervention measures were extracted. Systematic reviews were assessed for quality of included studies using a measurement tool (i.e., "AMSTAR 2").

RESULTS

In total, 37 studies were included, among which 21 (57 %) were of high or moderate quality. Strong evidence suggested that lower weight (P < 0.001), lower body mass index (P = 0.002), and non-stability defects (P = 0.04) significantly reduced the risk of developing CAI. Strong evidence supported exercise and moderate evidence supported manual therapy, acupuncture, and surgery for improving CAI. Additionally, external support plays an active role in the treatment process of CAI.

CONCLUSION

This is the first study synthesizing evidence supporting interventions for the treatment and prevention of CAI. Low body weight and body mass index were effective preventive measures against CAI. Exercise, manual therapy, acupuncture, and surgery can improve ankle function in patients with CAI. Plantar sensory treatment and neuromuscular training may be good therapeutic options for patients with CAI.

LEVEL OF EVIDENCE

Level I.

Lateral ankle instability - repair/ reconstruct what's new

Lateral ankle instability is a common condition which responds well to non-surgical management. However, the chronic symptomatic instability may require surgical intervention. The acceptable and practiced procedure is the Brostom Gould modification and it has a high patient satisfaction score. However, the current understanding and newer techniques for stabilising the lateral ligament complex has resulted in arthroscopic repairs, augmentation and tendon graft reconstructions. The literature does not provide an answer to the efficacy of these new techniques but there is some preliminary information favouring some of the latest procedures. It is now accepted practise to include ankle arthroscopy as a pre repair step. Augmentation of anatomical repair is also favoured in a select group of patients. This article provides an up to date account of the newer techniques for lateral ankle stabilisation.

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.

Ligament Augmentation Reconstruction System (LARS) for Ankle Lateral Ligament Reconstruction in Higher-Risk Patients: A 5-Year Prospective Cohort Study

Background:

The modified Broström-Gould (MBG) procedure is the gold standard for patients with chronic ankle instability (CAI), but it is relatively contraindicated for patients with higher body weight or generalized ligamentous laxity (GLL). The use of the ligament augmentation reconstruction system (LARS) is an alternative.

Hypothesis:

It was hypothesized that clinical outcomes would be similar in patients with increased body weight (>90 kg) or GLL, relative to controls.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

A total of 66 patients satisfying the inclusion criteria were invited to participate and were divided into 3 groups: controls (no risk factors for inferior clinical outcome), patients with body weight >90 kg, and patients with GLL (Beighton score, ≥5 of 9). All patients underwent imbrication of the lateral collateral ligament complex augmented with the LARS. Primary outcomes of interest were Tegner activity scale (TAS) and Foot and Ankle Outcome Score (FAOS) subscale scores. Secondary outcomes were recurrence of ankle instability, the need for further surgery, and/or complications. Patients were reviewed at 2 and 5 years postoperatively, and outcomes between groups were compared using repeated-measures analysis of variance.

Results:

Complete data were available for 63 patients (21 patients in each group). TAS improved in all groups from preoperatively to 2 years and 5 years postoperatively (P < .001 for all). Relative to the controls, the TAS scores were lower in the >90-kg group at 2 years and 5 years (P < .001 for both periods), while the GLL group had similar scores to controls at both postoperative periods. Both the >90-kg and the GLL groups showed no significant difference in improvement on any FAOS subscale scores relative to the controls, at both 2 and 5 years postoperatively. There were no recurrences, repeat surgeries, or major complications.

Conclusion:

Relative to controls, patients with body weight >90 kg or GLL had similar FAOSs, and TAS scores were lower in the >90-kg group, at 2 and 5 years, after the use of the LARS to augment lateral collateral ligament imbrication for CAI. Use of the LARS in this manner is a viable option in patients for whom the MBG procedure is relatively contraindicated.

Proprioception and neuromuscular control at return to sport after ankle surgery with the modified Broström procedure

The modified Broström procedure (MBP) is an initial treatment for symptomatic chronic ankle instability (CAI) patients. This study aimed to compare the proprioception and neuromuscular control ability of both affected and unaffected ankles at the time of return to sports after MBP for patients with scores of normal controls. 75 individuals (40 who underwent MBP, 35 normal controls) participated. The dynamic balance test scores were significantly higher in the affected ankle of the patients than in the controls (1.5 ± 0.6° vs. 1.1 ± 0.4°, p < 0.003). The time to peak torque for dorsiflexion (60.8 ± 13.9 ms vs. 52.2 ± 17.5 ms, p < 0.022) and eversion (68.9 ± 19.1 ms vs. 59.3 ± 21.1 ms, p < 0.043) was significantly delayed in the affected ankle of the patients than in the controls. The dynamic balance test and time to peak torque in CAI patients remained significantly reduced at the time of return-to-sport after MBP. Clinicians and therapists should be aware of potential deficits in proprioception and neuromuscular control when determining the timing of return to sports after MBP.

Suture Tape Augmentation in Lateral Ankle Ligament Surgery: Current Concepts Review

Chronic lateral ankle instability (CLAI) is a condition that is characterized by persistent disability and recurrent ankle sprains while encompassing both functional and mechanical (laxity) instability. Failure of conservative treatment for CLAI often necessitates operative intervention to restore the stability of the ankle joint. The traditional or modified Broström techniques have been the gold standard operative approaches to address CLAI with satisfactory results; however, patients with generalized ligament laxity (GLL), prior unsuccessful repair, high body mass index, or high-demand athletes may experience suboptimal outcomes. Synthetic ligament constructs have been tested as an adjunct to orthopedic procedures to reinforce repaired or reconstructed ligaments or tendons with the hope of early mobilization, faster rehabilitation, and long-term prevention of instability. Suture tape augmentation is useful to address CLAI. Multiple operative techniques have been described. Because of the heterogeneity among the reported techniques and variability in postoperative rehabilitation protocols, it is difficult to evaluate whether the use of suture tape augmentation provides true clinical benefit in patients with CLAI. This review aims to provide a comprehensive outline of all the current techniques using suture tape augmentation for treatment of CLAI as well as present recent research aimed at guiding evidence-based protocols.

Ankle instability – review and new trends

Ankle instability is an old topic with increasing importance in Orthopaedics’ world, as we start now realising how underdiagnosed this pathology has been. A lot of effort has been made in recent years to better understand the pathomechanics of this injury, with new surgical techniques being tried and even new anatomic structures being described. The objective of this paper is to review and compile the most important and recent literature on this matter, in an academic way, but oriented to clinical practice, so it can help surgeons keep updated in this so important subject.