SLR - June 2014 - Scott M. Walrath

Accelerated Versus Traditional Rehabilitation After Anterior Talofibular Ligament Reconstruction for Chronic Lateral Instability of the Ankle in Athletes.
 
Reference:  Miyamoto W., Takao M., Yamada K, Matsushita T. Accelerated Versus Traditional Rahabilitation After Anterior Talofibular Ligament Reconstruction for Chronic Lateral Instability of the Ankle in Athetes. The American Journal of Sports Medicine.  2014 Apr 10; 42(6): 1441-7.

Scientific Literature Review
 
Reviewed By: Scott M. Walrath, DPM
Residency Program: St. Vincent Hospital/WMC.  Worcester, MA

Podiatric Relevance: Chronic lateral ankle instability and pain is a common problem that plagues many athletes. When conservative measures have failed to resolve or improve pain and function, the Brostrom-type anatomic repair has been successful in treating patients. However, in some patients that have insufficient remnants of the lateral ankle ligaments are not suited for this type of repair and may require an anatomic reconstruction using autogenous graft. In these cases stabilization procedures like Watson-Jones, Evans and Christman-Snook have been utilized. These procedures have classically all required a post-operative period of immobilization lasting four weeks and non-weight bearing time of two weeks in order to be successful. Recent biomechanical studies have suggested that interference screws provide sufficient initial fixation strength at the bone-autograft attachment site. This in theory would allow the patient to advance the rehabilitation time, without a period of immobilization, post operatively. This would have a significant advantage for patients wanting a quick return activity.
   
Methods: The purpose of this study was to compare clinical outcomes after lateral ankle reconstructive surgery in patients that received a standard post-operative management of immobilization with those that received post-operative management that included early rehabilitation without immobilization. Participants in the study are all athletes who had suffered inversion ankle sprains during their activity and have had ankle instability for more than six months and failed conservative treatment for at least three months. The inclusion criterion is described as: Talocrural instability on stress radiography (described as anterior drawer test > 6mm or talar tilt >5 degrees), stable subtalar joint on talocalcaneal stress radiography without need for CFL reconstruction, healthy contralateral ankle and no other ankle pathologies in the affected ankle.

Patients were divided into two groups, Group 1 which had reconstruction with post-operative cast immobilization, and Group A which had reconstruction with an accelerated rehabilitation without postoperative immobilization. Each group underwent an anatomic reconstruction of the ATFL utilizing a gracilis autograft with an interference fit anchoring system. No significant differences in the procedure where reported.

Post-operative management of group one included immobilization in a short leg cast for four weeks, then a soft ankle orthosis for four weeks. Two-weeks post-operative weight bearing was allowed with the short cast. At four weeks full weight bearing was allowed in soft ankle orthosis. Once cast was removed, range of motion exercises to restore motion and strength conducted by a physical therapist. Training on treadmill, balance board and sport specific drills started six to seven weeks out. Soft ankle orthosis was removed at eight weeks.

Group A management included a soft ankle orthosis immediately after surgery for eight weeks, and weight bearing was allowed without restriction with pain as the patients limiting factor. Physical therapy for range of motion and strength started two days after surgery. Training on treadmill, balance board and sport specific drills started two to three weeks out. Soft ankle orthosis was removed at eight weeks. Both groups were allowed to jog as soon as they achieved full weight bearing without pain.
 
Results: All patients were evaluated before surgery, and again two years after surgery using the Karlsson and Peterson scoring system. At the two year follow up, Group 1 had improved significantly from an average score of 62.3 +/- 4.7 before surgery, and 94.4 +/-7.1 after surgery. The talar tilt angle compared with contralateral side also improved from 8.7 +/- 2.6 to 3.8+/-1.5 post-operatively. The anterior displacement of the talus was 7.7 +/-1.8 to 4.0+/-1.6 after. Group A showed similar improvement, with a increase in Karlsson and Peterson score from 64.1 +/- 4.8 to 91.7 +/-7.7. Talar tilt improved from 10.5 +/- 3.4 to 4.3+/-1.8 and the anterior displacement of the talus improved from 8.7 +/-2.1 to 4.3+/-1.2. So, at the two year follow up there was no statistical difference between the two groups.  No surgical complications such as a superficial or deep infection, nerve injury or DVT were seen in either group. 

Conclusions: Both groups had statistically similar improvements in the Karlsson and Peterson scoring system, as well as talar tilt and anterior displacement of the talus. No cases of re-injury were reported and difference in performance or ability was observed between groups. This study would suggest that early physical therapy and range of motion should be encouraged in patients reconstruction with autograft reconstruction of the ATFL, which can greatly reduce the amount of time the patient is absent from activity.   

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