SLR - August 2019 - Matthew J. Fernandez

Anterior Talofibular Ligament (ATFL) Repair Using Two Suture Anchors Produced Better Functional Outcomes Than Using One Suture Anchor for the Treatment of Chronic Lateral Ankle Instability

References: Hong Li, Yinghui Hua, Hongyun Li, Shiyi Chen. Anterior Talofibular Ligament (ATFL) Repair Using Two Suture Anchors Produced Better Functional Outcomes Than Using One Suture Anchor For the Treatment of Chronic Lateral Ankle Instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2019 June 05.1-6

Scientific Literature Review

Reviewed By: Matthew J. Fernandez, DPM
Residency Program: University of Florida Health – Jacksonville, FL

Podiatric Relevance: Chronic lateral ankle instability is a common musculoskeletal problem podiatric physicians face with the most common ligament involved being the anterior talofibular ligament (ATFL). An increasing number of surgeons are performing arthroscopic repairs of the ATFL for lateral ankle instability. Studies have shown that the use of one suture anchor has a lower failure load than that of an intact ATFL, which has caused some surgeons to use two suture anchors. However, there have not been studies comparing functional outcomes between one versus two suture anchor repair techniques. This study focused on if there was a difference in clinical outcomes for one versus two suture anchors in the repair of the ATFL for chronic lateral ankle instability.

Methods: Consecutive patients who underwent arthroscopic repair by a single surgeon were enrolled. 51 total patients were included (20-one suture anchor & 31-two suture anchors). Surgical technique and postoperative management were the same with the exception of placement of one versus two suture anchors in the fibula. Patients were followed for a minimum of two years either by telephone or clinic visits while AOFAS scores, Karlsson scores, and Tegner Activity scores were recorded. In addition to the noted scores, the patients were clinically evaluated with the anterior drawer test bilaterally. Patients were excluded if there was obvious bony deformity, neuromuscular disorder, general joint laxity, or augmented repair with tendons. There were no significant differences between the two groups in age, BMI, sex, or follow-up time. The authors secondarily evaluated the repairs with an MRI postoperatively.  

Results: Postoperatively, no patient in either group suffered from continued lateral ankle instability or had a positive anterior drawer test at two years. There also were no wound infections in either group and no patients required a revision. No significant difference in AOFAS score was noted (90±9 vs 91±10), but the two-anchor group did have a significantly better Karlsson (88±12 vs 80±14 p=0.04) and Tegner (5±1 vs 4±1 p<0.001) score. 21 patients in the two-anchor group returned to the pre-injury sport level compared to 6 patients in the one anchor group. Fifteen patients in the two-anchor group and 12 patients in the one anchor group had MRI scans at final follow up. The repaired ATFL could be identified in both groups on MRI. The one anchor group showed a low signal intensity on one slice, while the two-anchor group had low signal intensity of both slices of MRI.

Conclusions: The authors concluded that the two-anchor repair technique produced better functional outcomes compared to the one anchor repair technique. While the AOFAS scores between the two groups were not significantly different, it primarily emphasizes pain and not function. The Karlsson and Tegner scores better evaluate function and were both significantly improved in the two-anchor repair group. This study showed higher midterm outcomes for arthroscopic ATFL repairs utilizing a two suture anchor technique compared to one suture anchor, but more research is necessary to determine long-term outcomes. 

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