SLR - April 2023 - Trenton Leo, DPM
Title: Nonanatomic All-Inside Arthroscopic Anterior Talofibular Ligament Repair With a High-Position Anchor versus Anatomic Repair: An Analysis Based on 3D CTReference: Lee, S. H., Yang, J. H., & Kim, I. (2022). Nonanatomic all-inside arthroscopic anterior talofibular ligament repair with a high-position anchor versus anatomic repair: an analysis based on 3D CT. The American Journal of Sports Medicine, 50(8), 2134-2144.
Level of Evidence: Level III
Scientific Literature Review
Reviewed By: Trenton Leo, DPM
Residency Program: Eastern Virginia Medical School, Norfolk, VA
Podiatric Relevance: Chronic ankle instability (CAI) is a pathology encountered by athletes with repetitive injuries, those with connective tissue disorders, and also in the general population. The anterior talofibular ligament (ATFL) often becomes attenuated or completed ruptured in individuals suffering from this condition. The Broström procedure and modified versions of it have shown great success in obtaining surgical correction. The primary goal of this study was to decipher whether placement of a knotless suture anchor at anatomic, subanatomic, and nonanatomic locations when repairing the ATFL can lead to different outcomes and prognoses
Methods: An 80-patient retrospective cohort review was completed which analyzed the outcomes of arthroscopic repair of the ATFL using three different suture anchor points completed by one surgeon. Arthroscopic portals were derived from the standard anteromedial and anterolateral landmarks with an additional accessory anterolateral portal being made for protection of the superficial peroneal nerve. The ATFL was repaired using a knotless anchor system along with attached suture all via arthroscopic measures. The independent variable being measured was the location of the anchor in respect to the fibular anterior tubercle (FAT) and the fibular obscure tubercle (FOT). These two osseous landmarks are cornerstones for minimally invasive surgery for CAI and have also been measured in respect to the ATFL attachment. Anatomic, subanatomic and nonanatomic areas of anchor placement were deemed at the lower quarter between the FAT and FOT, second quarter between the FAT and FOT, and the upper half between the FAT and FOT respectively. CT’s were obtained at an average of 3.25 days post-operatively to stratify the subgroups. VAS pain, AOFAS, FAOS, and Karlsson instability scores were measured for outcome analysis.
Results: Once all inclusion and exclusion criteria were accounted for, the anatomic, subanatomic and nonanatomic groups had 24, 42, and 14 patients respectively. No significant differences in confounding variables such as age, sex, follow-up period, smoking status, BMI, generalized hyperlaxity, arthroscopic ATFL grade, and concomitant intra- articular lesions were found between the groups. All patients had a minimum follow-up of 24 months. The VAS pain, AOFAS, FAOS, and Karlsson instability scores all significantly improved post-operatively for the anatomic and subanatomic groups, however only the VAS pain score improved for the nonanatomic group. The fall risk and general stability index improved in the anatomic and subanatomic groups but not the nonanatomic group. There were no significant differences shown in retear rates between the three groups. In comparison between the anatomic and the nonanatomic repair groups, all findings were significantly improved in the anatomic group compared to the nonanatomic group except for VAS pain score.
Conclusions: This study outlines the importance of ensuring proper anchor placement in respect to the anatomic ATFL attachment when performing an arthroscopic Broström repair. This can be achieved by debriding all necessary impeding soft tissue off the distal lateral malleolus and following proper arthroscopic principles. The improved prognosis when obtaining an anatomic repair is evident via the study and emphasizes the meticulous care surgeons must undergo in order to certify an optimal repair.