SLR - May 2016 - Joseph H. Bahn

Title: Activity Level and Function After Lateral Ankle Ligament Repair Versus Reconstruction
Reference: Matheny LM, Johnson NS, Liechti DJ, Clanton TO. Activity Level and Function After Lateral Ankle Ligament Repair Versus Reconstruction. Am J Sports Med. 2016 Feb 26.  

Scientific Literature Review

Reviewed By: Joseph H. Bahn, DPM
Residency Program: Massachusetts General Hospital, Boston, MA

Podiatric Relevance: Ankle sprains are common musculoskeletal injuries encountered in practice. The anterior talofibular ligament (ATFL) and calcaneal fibular ligament (CFL) are the most commonly affected lateral ankle ligaments. ATFL and CFL injuries can lead to chronic ankle instability and long term disability. The authors stated the gold standard of treatment for repairing lateral ankle ligaments has been described by Gould et al with modified Broström involving attaching the inferior extensor retinaculum to the fibula. However, in failed prior secondary repairs or reconstruction, chronic instability with poor tissue, large athletes and hyperflexible tissues, the Broström-Gould procedure may be contraindicated. Anatomic allograft reconstruction is indicated in such situations. Many studies have investigated the outcome of both procedures with good results. This study compares the outcome of function and activity level with revision rates after both procedures.  

Methods: A retrospective review was performed on patients who were treated for ankle instability, from 2009 through 2013 by a single surgeon. Sixty-one patients were treated with Broström-Gould procedure and 25 were treated with allografts when the remaining ligaments were not sufficient for the repair procedure. Patients were emailed with a subjective questionnaire at a minimum of two years following the procedure. They included the American Orthopaedic Foot and Ankle Society (AOFAS), Ankle-Hindfoot Scale, Lysholm score, Foot and Ankle Disability Index score, Western Ontario and McMaster Universities Arthritis Index (WOMAC) score.   

Results: A total of 86 patients (45 males, 41 females) were included, average patient age of 38 years (range, 19-68 years) with mean BMI of 26.5 (range, 17.5-47.1). Of the 86 patients, 61 (71 percent) were treated with Broström-Gould and 25 (29 percent) with reconstruction procedure. Fifty-one of the Broström-Gould group had both ATFL and CFL repair and 24 of the 25 reconstruction group had both ATFL and CFL repair. Ten patients were lost for follow up at minimum two years. No patient underwent revision surgery in either group. The two groups showed no significant difference in function, pain, general health, activity level and showed similar patient satisfaction and outcome.

Lateral ankle ligament injuries can result in long term disability and chronic ankle arthritis. Broström-Gould has been advocated by many authors for standard treatment of care for repairing lateral ankle ligaments. However, it requires enough soft tissue and may be contraindicated in a revision procedure. When direct repair of the ligament is contraindicated, using an allograft for reconstruction of the lateral ankle ligament repair has been described in the literature with satisfactory results. There was no significant difference in function and activity levels of patients that have had the Broström-Gould procedure and reconstruction with allograft. This retrospective cohort study serves to illustrate that lateral ligament repair reconstruction with allograft is a promising choice of procedure that is comparable to direct repair. 

Educational Opportunities