SLR - June 2019 - Megan E. Hom
Ankle Lateral Ligament Augmentation Versus the Modified Broström-Gould Procedure: A Five-Year Randomized Controlled Trial
Reference: Porter M., Shadbolt B., Ye X., Stuart R. Ankle Lateral Ligament Augmentation Versus the Modified Broström-Gould Procedure: A Five-Year Randomized Controlled Trial. Am J Sports Med. 2019 Mar;47(3).
Scientific Literature Review
Reviewed By: Megan E. Hom, DPM
Residency Program: Kaiser Permanente Vallejo, North Bay Consortium, Vallejo, CA
Podiatric Relevance: Lateral ankle stabilization is a common procedure performed, especially in sports medicine. The modified Broström-Gould (MBG) has been the “gold standard” for treatment of lateral ankle instability; however, in elite athletes or high BMI, it may not be strong enough. Previous literature on the long-term outcomes of MBG have not been entirely convincing on the longevity of the procedure. Ligament augmentation reconstruction system (LARS) uses a synthetic ligament to act as an extracapsular scaffold for the native tissue repair. The purpose of this study is to compare patient-scored outcomes and activity levels after the Modified Broström-Gould and the LARS. The authors’ hypothesis was that there would be no difference between the surgical techniques.
Methods: Level I Randomized Control Study. All surgeries were performed by the main author. Inclusion criteria were patients with chronic instability of the ATFL and CFL, medically fit, physically active, failed nonoperative treatment and skeletally mature. Exclusion criteria were those with previous ankle surgery, MBG contraindications (i.e., generalized ligament laxity, rearfoot varus, previously failed MBG, >24 months of ankle instability, etc.) and >90 kg body mass. Patients were randomly split into MBG or LARS treatment and underwent the same postoperative protocol. MBG was performed with suture anchors to repair the ATFL and CFL and incorporation of the inferior extensor retinaculum. LARS was performed with Arthrex Swivel Lock screws into the talus, calcaneus and fibula to recreate ATFL and CFL using the LARS synthetic ligament. The capsule was imbricated deep to the repair in a manner similar to MBG. Foot and Ankle Outcome Scores were gathered preoperatively, and then one year, two years and five years postoperatively. Tegner activity scores were measured five years postoperatively.
Results: There were 22 LARS and 25 MBG patients. Both groups had significant improvement in total scores, pain, other symptoms, activities of daily living, sports, quality of life and Tegner Activity Score. However, LARS had significantly superior results than MBG in the Tegner Activity Score, ADLs, sports, quality of life and overall total score. There were three complications in the LARS group (two infections, one swivel lock irritation) and two in MBG (one pseudoaneurysm, one infection). There were three recurrent injuries in the MBG group.
Conclusions: Patients who are physically active with chronic lateral ankle instability had superior outcomes in FAOS and Tegner scores after LARS augmentation of repair compared to MBG five years postop with similar complications risks. This is worth noting, especially in athlete populations where many are >90 kg or have generalized ligament laxity (dancing, gymnastics, etc.) and MBG is relatively contraindicated. These patients were excluded to prevent bias against MBG, and the authors noted the next step would be to compare LARS in patients with and without contraindications to MBG procedure. Some limitations include no objective outcome measures and a relatively aggressive postoperative protocol that may have stressed the MBG repairs too early. A longer patient follow-up to assess for progression of ankle arthritis between the patient groups would be worth pursuing as well.