The Addition of an “Internal Brace” to Augment the Broström Technique for Lateral Ankle Ligament Instability

High incidence of post-operative re-sprain following suture tape implantation for anterior talofibular ligament insufficiency and risk factors for post-operative re-sprain

PURPOSE

Anterior talofibular ligament (ATFL) insufficiency encompasses situations in which (i) frequent sprains cause ATFL loss, as evidenced by ATFL non-visualization on preoperative magnetic resonance imaging; or (ii) minimal healthy ATFL tissue for repair is left after the removal of the large os subfibulare. Suture tape implantation can be indicated for these cases rather than conventional ligament repair. This study was designed to investigate the incidence of post-operative re-sprain in patients who underwent suture tape implantation for ATFL insufficiency, and risk factors influencing the occurrence of post-operative re-sprain were identified.

METHODS

A total of 68 patients who underwent suture tape implantation for ATFL insufficiency from January 2016 to December 2021 were retrospectively evaluated. The minimum follow-up duration for inclusion was 2 years after surgery. All included patients were divided into two groups according to the presence of post-operative re-sprain during the follow-up period. Multiple clinico-radiographic parameters were measured, and binary logistic regression analysis was performed to determine the factors influencing post-operative re-sprain.

RESULTS

Post-operative re-sprain occurred in 19 of the 68 patients (27.9%), and multiple re-sprains persisted in 7 patients (10.3%). Post-operative re-sprain was more likely to occur in patients who smoked after surgery (odds ratio [OR], 3.510), had generalized ligament laxity (OR, 4.364) and engaged in occupations requiring high physical activity levels (OR, 4.421), including soldiers, professional athletes, student-athletes and mailmen.

CONCLUSION

The incidence of multiple post-operative re-sprains was high after suture tape implantation for ATFL insufficiency. Caution is particularly warranted in patients with risk factors, necessitating meticulous attention to their care. Careful consideration of strategies to mitigate risks when performing the surgery is also recommended.

LEVEL OF EVIDENCE

Level III.

Broström Repair With and Without Augmentation: Comparison of Outcomes at Median Follow-up of 5 Years

BACKGROUND

An augmented Broström repair with nonabsorbable suture tape has demonstrated strength and stiffness more similar to the native anterior talofibular ligament (ATFL) compared to Broström repair alone at the time of repair in cadaveric models for the treatment of lateral ankle instability. The study purpose was to compare minimum 2-year patient-reported outcomes (PROs) following treatment of ATFL injuries with Broström repair with vs without suture tape augmentation.

METHODS

Between 2009 and 2018, patients >18 years old who underwent primary surgical treatment for an ATFL injury with either a Broström repair alone (BR Cohort) or Broström repair with suture tape augmentation (BR-ST Cohort) were identified. Demographic data and PROs, including Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sport subscales, 12-Item Short Form Health Survey (SF-12), Tegner Activity Scale, and patient satisfaction with surgical outcome, were compared between groups, and proportional odds ordinal logistic regression was used.

RESULTS

Ninety-one of 102 eligible patients were available for follow-up at median 5 years. The BR cohort had 50 of 53 patients (94%) completed follow-up at a median of 7 years. The BR-ST cohort had 41 of 49 (84%) complete follow-up at a median of 5 years. There was no significant difference in median postoperative FAAM ADL (98% vs 98%, P = .67), FAAM sport (88% vs 91%, P = .43), SF-12 PCS (55 vs 54, P = .93), Tegner score (5 vs 5, P = .64), or patient satisfaction (9 vs 9, P = .82). There was significantly higher SF-12 MCS (55.7 vs 57.6, P = .02) in the BR-ST group. Eight patients underwent subsequent ipsilateral ankle surgery, of which one patient (BR-ST group) was revised for recurrent lateral ankle instability.

CONCLUSION

At median 5 years, patients treated for ATFL injury of the lateral ankle with Broström repair with suture tape augmentation demonstrated similar patient-reported outcomes to those treated with Broström repair alone.

LEVEL OF EVIDENCE

Level II, retrospective cohort study.

Clinical Outcomes After Suture Tape Augmentation for Ankle Instability: A Systematic Review

Background:

There is minimal literature on the use of suture tape augmentation in the treatment of chronic lateral ankle instability (CLAI), prompting an investigation on its use and effect during surgery of the lateral ankle.

Purpose:

To evaluate the evidence for the use of suture tape augmentation in the treatment of CLAI and the outcomes after this procedure.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A literature search was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they evaluated the use of suture tape for CLAI. Outcome measures included the Foot and Ankle Ability Measure, American Orthopaedic Foot and Ankle Society (AOFAS) score, return to play, and radiological improvement in anterior talar translation and talar tilt angle. Quantitative and qualitative analyses were performed.

Results:

There were 11 studies (2 with level 2 evidence, 1 with level 3, and 8 with level 4) including 334 patients (334 ankles) that underwent suture-tape augmentation. The mean age was 27.3 years, 67.3% were women, and the mean follow-up was 27.6 months (range, 11.5-38.5 months). The mean weighted postoperative AOFAS score was 95, and 87.7% were able to return to sports. Overall, 9 recurrent instability events (4.1%) were reported. In 3 studies that compared Broström repair and suture tape augmentation, there were no significant differences between the procedures in recurrent instability (mean difference [MD], 0.81 [95% CI, 0.19 to 3.50]; I² = 0%; P = .78), Foot and Ankle Ability Measure (MD, 1.24 [95% CI, –3.73 to 6.21]; I² = 66%; P = .63), talar tilt angle improvement (MD, –0.07 [95% CI, –0.68 to 0.54]; I² = 0%; P = .42), or anterior talar translation improvement (MD, –0.06 [95% CI, –0.69 to 0.56]; I² = 0%; P = .77).

Conclusion:

Suture tape augmentation did not significantly improve clinical or radiological outcomes in the setting of modified Broström repair for CLAI. There is currently insufficient evidence to recommend suture tape augmentation for all patients at this time.

Biomechanical Evaluation of Suture Tape Internal Brace Reinforcement of Soft Tissue Allografts for ACL Reconstruction Using a Porcine Model

Background:

Internal bracing of anterior cruciate ligament (ACL) surgery is a newer concept gaining popularity.

Purpose/Hypothesis:

To assess the biomechanical performance of soft tissue ACL reconstruction allografts reinforced with suture tape. It was hypothesized that load to failure would increase and cyclic displacement would decrease at time zero in the constructs reinforced with internal brace suture tape compared with those without suture tape augmentation.

Study Design:

Controlled laboratory study.

Methods:

We performed ACL reconstruction on porcine knees using bovine extensor tendon soft tissue allografts: 10 knees without (control) and 10 knees with (reinforced) suture tape reinforcement. An all-inside reconstruction technique was utilized with retrograde tunnel creation. An adjustable-loop device was used for femoral and tibial fixation of all grafts. The suture tape was placed through the tension loop in the femoral fixation construct and independently fixed in the tibia with an interference screw anchor. For each specimen, the authors recorded ultimate load, yield load, stiffness, cyclic displacement, and mode of failure. Outcomes between groups were compared using the Student t test.

Results:

There was a 33% decrease in mean cyclic displacement in the specimens with reinforced grafts (reinforced vs control: 3.9 ± 0.7 vs 5.8 ± 1.5 mm; P = .001). The reinforced grafts also had a 22% higher mean ultimate load (921 ± 180 vs 717 ± 122 N; P = .008) and a 25% higher mean yield load (808 ± 201 vs 602 ± 155 N; P = .020). There was no significant difference in stiffness between the reinforced versus nonreinforced grafts (136 ± 16 vs 132 ± 18 N/mm; P = .617). Three of the 10 control specimens failed at the graft, compared with 1 of 10 reinforced grafts. All other constructs in both groups failed at the tibial fixation site.

Conclusion:

Suture tape reinforcement of soft tissue grafts significantly decreased cyclic displacement while significantly increasing ultimate and yield loads without increasing graft construct stiffness during biomechanical testing at time zero in a porcine animal model.

Clinical Relevance:

The improved biomechanical performance of suture tape–reinforced graft constructs could allow patients to participate in earlier advancement of aggressive rehabilitation and potentially reduce failure rates as graft remodeling progresses.

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.

Evaluation of the Intact Anterior Talofibular and Calcaneofibular Ligaments, Injuries, and Repairs With and Without Augmentation: A Biomechanical Robotic Study

BACKGROUND

Acute ankle sprains are common injuries. The anterior talofibular (ATFL) and calcaneofibular ligaments (CFL) are the most injured lateral structures. However, controversy exists on the optimal surgical treatment when the injury is both acute and severe or becomes chronic and unstable. Studies have evaluated the biomechanics of these ligaments, but no studies have robotically evaluated injury effects and surgical treatment of ATFL or ATFL and CFL injuries.

PURPOSE

To quantitatively evaluate biomechanical effects of ATFL and CFL lesions, ATFL repair, ATFL and CFL repair, and augmentation of ATFL on ankle stability.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten nonpaired cadaveric ankles were tested using a 6 degrees of freedom robot. Each ankle underwent testing in the following states sequentially: (1) intact, (2) ATFL cut, (3) CFL cut, (4) ATFL repair + CFL cut, (5) ATFL repair + CFL repair, and (6) ATFL repair with augmentation with suture tape + CFL repair. Testing included 88 N anterior drawer and 5 N·m varus talar tilt tests at 0° and 30° of plantarflexion, and 88 N Cotton test at 0° of plantarflexion.

RESULTS

After all surgical treatments ankles still had increased laxity compared with intact state testing, except after augmented ATFL repair + CFL repair in anterior drawer testing at 30° of plantarflexion (P = .393). Sectioning the CFL caused a significant increase in talar tilt compared with the ATFL cut state at 0° (P < .001) and 30° of plantarflexion (P < .001), but no increase in anterior drawer or Cotton tests.

CONCLUSION

Complete native stability may not be attainable at time zero repair with the tested treatments. The option that best returned stability in anterior translation was augmented ATFL repair with nonaugmented CFL repair. The importance of the CFL as a primary ligamentous stabilizer for talar tilt was confirmed.

CLINICAL RELEVANCE

Evaluating lateral ankle stability and treatment with a 6 degrees of freedom robot should help delineate optimal treatment options. Findings in this study show that none of the repair methods at time zero restored kinematics to the intact state. Of the tested states, the augmented ATFL repair with CFL repair was the best option for controlling anterior translation at time zero. The importance of addressing the CFL to correct talar tilt instability was suggested as was the importance of a period of immobilization before beginning protected rehabilitation. The benefit of ATFL repair augmentation with suture tape is in limiting the postoperative motion in an anterior drawer motion to just 0.5 to 1 mm, but there was no significant improvement to talar tilt even with CFL repair, suggesting that further consideration should be given to CFL augmentation in future studies.

A Systematic Review of Angular Deformities in Charcot Neuroarthropathy

Charcot neuroarthropathy of the foot and ankle is associated with periarticular deformities and progressive radiographic changes. There have been studies analyzing the radiographic angulations and deformity progression in Charcot neuroarthropathy deformity. The aim of this paper is to provide systematic review of studies that evaluate foot and ankle radiographic parameters in patients with Charcot neuroarthropathy. A multidatabase search including, medline, EMBASE, Google Scholar, Cochrane Library, Clinicaltrials.gov and reference lists of included studies, was performed from 1980 to 2020. A total of 7 articles were included that analyzed radiographic angulations in Charcot neuroarthropathy deformity. The articles could be categorized into nonoperative angulation measurements, and pre- versus postoperative angulation measurements. The presence of ulcerations and the severity of the Charcot neuroarthropathy deformity were found to result from predominantly sagittal plane deformity. The deformity initiates with medial column collapse and progresses to continual lateral column collapse. Surgical intervention resulting in immediate postoperative improvement in angular measurements, however, without beaming of both the medial and lateral column, there was recurrence of the lateral column deformity. This systematic review of articles analyzing angular deformities in Charcot neuroarthropathy patients, demonstrates the progressive sagittal plane breakdown patterns of Charcot as well as the benefits of surgical intervention.

Arthroscopic Surgical Technique for Lateral Ankle Ligament Instability

In the past several years, arthroscopic repair of the lateral ankle ligaments has grown because it has shown comparable results with the traditional open Brostrom-Gould procedure. In addition, arthroscopic repair allows reduced swelling and cosmesis. This article discusses the authors' technique for lateral ankle instability, with published data supporting biomechanical equivalency to the standard open Brostrom-Gould procedure. An optional internal brace can provide further strength to the repair and lead to a quicker recovery. Arthroscopic repair both with and without the internal brace have shown positive clinical outcomes for patients as well as high satisfaction rates.

Stabilizing lateral ankle instability by suture tape - a cadaver study

BACKGROUND

Suture tape is a recent development to augment a Brostrom repair at least during the healing phase of the native tissues used for stabilization of the lateral ankle ligaments. The purpose of this study was to evaluate whether suture tape is an effective mechanical stabilizer against anterior talar drawer in a cadaver experiment when tested with a validated arthrometer.

METHODS

Different stability conditions were created in 14 cadaveric foot and leg specimens. Following anterior talofibular ligament (ATFL) dissection, isolated suture tape ATFL reconstruction was compared to the unaltered specimens, to the condition with ATFL cut, to the ATFL plus calcaneofibular ligament (CFL) cut conditions, and to the ATFL, CFL, and posterior talofibular ligament transected specimens. Three-dimensional bone-to-bone movement between fibula and calcaneus were simultaneously recorded using bone pin markers. Anterior translation was analysed between 20 and 40 N anterior talar drawer load, applied by an ankle arthrometer. Test conditions were compared using non-parametric statistics.

RESULTS

Dissection of ATFL increased anterior talar drawer in arthrometer and bone pin marker analyses (p = 0.003 and 0.004, respectively). When the CFL was additionally cut, no further increase of the anterior instability could statistically be documented (p = 0.810 and 0.626, respectively). Following suture tape reconstruction of the ATFL, stability was not different from the unaltered ankle (p = 0.173).

CONCLUSIONS

Suture tape augmentation of the ATFL effectively protects the unstable anterolateral ankle in the sagittal plane. The CFL does not seem to stabilize against the anterior talar drawer load.

[Lateral ankle ligament bracing]

OBJECTIVE

Covering the anatomic reconstruction (Broström procedure) with suture tape for more initial stability. Seat belt principle.

INDICATIONS

Mechanical lateral ankle instability: athletes in sports at risk, patients with uncertain compliance with respect to the postoperative treatment regimen, patients with poor tissue quality, patients with generalized laxity, and patients with failed previous repairs.

CONTRAINDICATIONS

Known implant intolerance, local or systemic infection, local soft tissue affections, hemorrhagic disorders.

SURGICAL TECHNIQUE

Epimalleolar 5 cm skin incision. Anatomic repair of the lateral capsuloligamentous structures to the anterior facet of the lateral malleolus (e.g. Broström repair). Dissection down to origin and insertion of the anterior talofibular ligament (ATFL). Close proximal (fibula) and distal (talar neck) to the ATFL attachments to bone a 2.7 mm (fibular) and a 3.4 mm (talar) drill hole is created and taped with the respective tapes from the single use kit (Arthrex, Naples, FL, USA). Placement of a 3.5 mm × 15.8 mm BioComposite SwiveLock® screw, preloaded with suture tape into the fibula. The free ends of this suture tape are inserted into a 4.75 mm × 19.1 mm SwiveLock® anchor, which is screwed into the talar drill hole under moderate tension of the suture tapes.

POSTOPERATIVE MANAGEMENT

Immobilization for 4-5 days postoperatively in a leg and foot Scotchcast^TM. Then, full load bearing within 1-2 days in a stable shoe (OrthoTECH Stabil, OrthoTECH GmbH, Stockdorf, Germany) for 5 postoperative weeks for the day and a night splint (existing Scotchcast^TM). Sensorimotor training initiated in the third and running in the eighth postoperative week. Return to competition in sports at risk (football, basketball, volleyball) 10-12 weeks postoperatively.

RESULTS

Measured with the validated FAAM-G (Foot and Ankle Ability Measure-German version) questionnaire, 9 patients had a preoperative activities of daily living subscale median (minimum-maximum) of 65 (30-100) and increased to 98 (78-100) 12 months postoperatively. Preoperative FAAM-G sport subscale results were 35 (0-75) and 100 (19-100) after 12 months. With the Sefton Grading System, 7 of 8 followed patients had an excellent result and had unrestricted ankle mobility and stable ankles (talar tilt and anterior talar drawer), which is comparable to published suture tape augmentation reports.

Chronic Lateral Ankle Instability: Open Surgical Management

Open surgical reconstruction for chronic lateral ankle instability is a proven and effective means of providing renewed stability. Ankle arthroscopy is recommended before reconstruction to address intra-articular pathology. The open procedure discussed is well researched and proven to restore stability and the ability to return to sport and daily activity. Anatomic shortening with reattachment into a bony trough allows return to full motion, reliable stability, and return to an active lifestyle without sacrificing any tendons or requiring a tenodesis. The authors' aggressive rehabilitation protocol is provided; the approach to athletes/patients with ligament laxity or cavovarus alignment is also addressed.

Operative treatment of lateral ligament instability

PURPOSE OF REVIEW

Ankle sprains, which account for 40% of sports injuries in the USA, can lead to chronic ankle instability. Chronic ankle instability can be classified as functional, mechanical, or a combination of both and is diagnosed using a combination of a physical exam, an MRI, and stress radiographs. This review focuses on different approaches to treatment, including non-operative and operative techniques, of chronic ankle instability, including reviewing traditional procedures as well as more novel and newer techniques.

RECENT FINDINGS

Based on existing literature, non-operative treatment should always precede operative treatment of chronic ankle instability. If rehabilitation fails, Brostrom-Gould type ankle stabilization has been the preferred surgical option. Recent literature suggests that arthroscopic repair might reduce recovery time and improve outcomes in certain populations; however, there are higher rates of complication following these surgeries. In more high-risk populations, some literature reports that ligament repair with peroneus brevis transfer could be a more effective treatment option. Currently, varying surgical techniques exist for the treatment of chronic ankle instability. While the more recently reported techniques show promise, it is important to note that there is little evidence showing they are more successful than traditional techniques. It is imperative that future studies focus on outcomes and complication rates of these newer procedures.