SLR - September 2021 - Raul Aviles

Additional Inferior Extensor Retinaculum Augmentation After All-Inside Arthroscopic Anterior Talofibular Ligament for Chronic Ankle Instability is not Necessary

Reference: Lee SH, Cho HG, Yang JH. Additional Inferior Extensor Retinaculum Augmentation After All-Inside Arthroscopic Anterior Talofibular Ligament for Chronic Ankle Instability is not Necessary. Am J Sports Med. 2021 Jun;49(7):1721-1731.

Level of Evidence: III

Scientific Literature Review

Reviewed By: Raul Aviles, DPM
Residency Program: SSM Health DePaul Hospital – St. Louis, MO

Podiatric Relevance: Operative indications for chronic lateral ankle instability include failure of functional rehabilitation. The traditional open method includes direct anatomic repair of the ligaments as described by Broström. The inferior extensor retinaculum’s calcaneal attachment is located approximately 10 millimeters anterior to the calcaneal fibular ligament which raises the question of whether it’s a true anatomic repair as it may limit plantarflexion of the ankle. The arthroscopic approach to the Broström provides a reliable construct but an additional inferior extensor retinaculum augmentation adds considerable operative time and may not provide much benefit. The study compares clinical outcomes of arthroscopic repairs with and without augmentation.

Methods: The study is a retrospective review of 82 patients with an average age of 35.2 years, mean follow up of 32.6 months, comparing two groups: arthroscopic ATFL repairs versus arthroscopic ATFL repairs with inferior extensor retinaculum augmentation. Subjective outcomes were measured by the visual analog scale, American Orthopaedic Foot & Ankle Society score, Foot and Ankle Outcome Score, and the Karlsson Ankle Function Score. Objective outcomes were measured by posturographic analysis using a Tetrax device.

Results: Significant improvement in the subjective outcomes were noted in both groups. No differences were noted in either surgical group in regard to clinical outcomes. Proprioception and stability were improved in both groups but there was no significant difference between the groups themselves.

Conclusions: Arthroscopic repair of the anterior talofibular ligament in chronic lateral ankle instability was noted to be beneficial with and without inferior extensor retinaculum augmentation. No additional improvement was noted with the augmentation as the retear rates remained comparable. In addition to longer operative time, Group R also reported six cases of neuritis and prominent knot irritation. This study demonstrates that augmentation is not essential and can be omitted without compromising reconstruction of the ATFL.  

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