SLR - November 2021 - Anne He

Arthroscopic All-Inside Anterior Talofibular Ligament Repair with and without Inferior Extensor Retinacular Reinforcement: A Prospective Randomized Study

Reference: Jo, J., Lee, Jin Woo., Kim, Hak Jun., Suh, Dong Hun., Kim, Won Seok., Choi, Gi Won. Arthroscopic All-Inside Anterior Talofibular Ligament Repair with and without Inferior Extensor Retinacular Reinforcement: A Prospective Randomized Study. The Journal of Bone and Joint Surgery. 2021;103:1578-87.

Level of Evidence: I

Scientific Literature Review

Reviewed By: Anne He, DPM
Residency Program: Scripps Mercy Hospital – San Diego, CA

Podiatric Relevance: The arthroscopic repair for chronic lateral ankle instability has become common in the podiatric field. Typically, the arthroscopic Broström technique involves lateral ankle ligament repair by either suturing to the capsuloligamentous structures or suturing directly to the ligament remnant. However, reinforcement using the inferior extensor retinaculum (IER) may or may not be performed. The authors hypothesized that the outcomes would not differ between arthroscopic ATFL repair with or without IER reinforcement.

Methods: This is a prospective randomized study of 73 patients who underwent arthroscopic all-inside ATFL repair with or without IER reinforcement at two institutions from May 2018 to August 2019. Inclusion criteria includes ankle giving-way, repetitive ankle sprain, positive inversion or anterior drawer test. Exclusion criteria include those with neuromuscular disorders, obvious foot/ankle osseous deformity, prior surgery or fracture of the foot/ankle, chronic lateral instability of the contralateral ankle, ligamentous laxity with Beighton score >4, and other conditions that required prior procedures. The patients were randomized but not blinded to two groups: arthroscopic ATFL repair with IER reinforcement or arthroscopic ATFL repair without IER reinforcement. Primary outcome was the Karlsson Ankle Functional Score (KAFS). The secondary outcomes include Foot and Ankle Outcome Score (FAOS), Tegner Activity Score (TAS), and range of motion of the ankle were evaluated preoperatively, at six and 12 months postoperatively, and radiographic parameters.

Results: The KAFS, FAOS, and TAS at one year postoperatively showed significant improvements compared to the preoperative values in both groups. There were no significant differences between both groups for all scores preoperatively, at six months and 12 months postoperatively. Ankle range of motion preoperatively showed no significant difference compared to six month or one year postoperatively in both groups. Radiographic outcomes of mean talar tilt and anterior talar translation decreased significantly at one year postoperatively in both groups. No differences between both groups when comparing values preoperative and one year postoperatively. Of note, one patient in the IER reinforcement group had an inversion injury two month postop and required subsequent surgery. His outcome was excluded from the results.

Conclusions: The authors concluded that at one year, no advantages were associated with performing reinforcement to the IER when done in addition with an arthroscopic all-inside ATFL repair. Furthermore, the functional and stress radiographic outcomes were comparable between arthroscopic all-inside ATFL repair with and without IER reinforcement. Therefore, performing IER reinforcement in addition to all-inside arthroscopic direct ATFL repair may not be necessary. From this article, I’ve concluded that the reinforcement of the IER can be dependent on a case-by-case basis. For instance, if the patient has more a severe lateral ankle instability or has more of an active lifestyle, I would highly consider the IER reinforcement in addition to the ATFL repair for more stability. Furthermore, the article also discussed other reports of knot related complications. If I decide on an IER reinforcement, I will consider looking at the real estate and ensure that I have adequate soft tissue coverage during closure to mitigate the possibility of suture knot complications.

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