SLR - December 2018 - Hyunho Choi

Repair of Only Anterior Talofibular Ligament Resulted in Similar Outcomes to Those of Repair of Both Anterior Talofibular and Calcaneofibular Ligaments

Reference: Ko KR, Lee WY, Lee H, Park HS, Sung KS. Repair of Only Anterior Talofibular Ligament Resulted in Similar Outcomes to Those of Repair of Both Anterior Talofibular and Calcaneofibular Ligaments. Knee Surg Sports Traumatol Arthrosc. 2018 Aug 6; 10.1007/s00167-018-5091-3.

Scientific Literature Review

Reviewed By: Hyunho Choi, DPM
Residency Program: Hoboken University Medical Center, Hoboken, NJ

Podiatric Relevance: The classic Broström procedure describes repair of the anterior talofibular ligament and calcaneofibular ligament, while Gould et al. described the modification with augmentation using the inferior extensor retinaculum. However, the need for CFL repair remains controversial and tends to be performed according to surgeons’ preferences. A prospective randomized controlled trial was conducted to compare the surgical outcomes of the modified Broström procedure with (CFL group) or without CFL repair (ATFL only group). The study aims to compare the functional and radiographic outcomes between the two groups and discuss the benefits of additional CFL repair. It was hypothesized that the ATFL only group with the augmentation of the inferior extensor retinaculum would show comparable outcomes.

Methods: The final study subjects included 50 patients. Inclusion criteria were symptom duration of more than six months, MRI findings of ATFL abnormality, positive anterior drawer test on physical exam, radiographic findings with >10 mm anterior talar translation on anterior drawer test and talar tilt ankle of >10 degrees on varus stress test. Exclusion criteria were age <20 or >50 and presence of other lower extremity diagnosis. A total of 43 patients (22 CFL group, 23 AFTL Only group) were followed up for ≥2 years. All surgeries were performed by the senior author, and arthroscopic exam was performed in all patients to identify intra-articular pathologies at the time of surgery. As for ATFL repair, either suture material or suture anchor was used depending on condition of remnant ligament. Thirteen suture anchors were used on the CFL group and 10 in the ATFL only group. Inferior extensor retinaculum was sutured to the periosteum of the fibular tip in all surgeries.

Results: Functional outcomes were measured with Karlsson-Peterson and Tegner activity level scores, which improved postoperatively (p<0.001), but no statistically significant difference was noted between the two groups. As for radiographic outcomes, anterior talar translation, talar tilt angle, anterior calcaneal translation and medial calcaneal translation were measured with no statistically significant difference between the two groups. Multiple regression analysis was performed to evaluate the effect of the CFL repair, use of suture anchor and the presence of intra-articular pathology. While other variables were not significant, the presence of osteochondral lesion of talus was the only significant variable (p=0.023).

Conclusion: Additional CFL repair while performing modified Broström procedure did not result in superior outcomes compared to those with AFTL repair alone. CFL has roles in stabilizing the subtalar joint as well as the ankle joint; therefore, the evaluation of the subtalar joint by measuring anterior and medial calcaneal translation was noteworthy. Authors reference that the anatomical vector of inferior extensor retinaculum is similar to the vector sum of the ATFL and CFL. Therefore, inferior extensor retinaculum repair can theoretically mimic the CFL repair. The presence of intra-articular pathologies and the use of suture anchors on some patients can be limitations of this study. Future randomized studies with stratification according to the presence or absence of osteochondral lesion of talus should be considered. 

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