Surgical management of chronic lateral ankle instability: a meta-analysis

Abstract

Background: A key point to surgical treatment of chronic lateral ankle instability is choosing a suitable surgical procedure. The purpose of this meta-analysis was to compare different surgical techniques for management of chronic lateral ankle instability.

Methods: We searched the Cochrane Library, MEDLINE, and EMBASE. All identified randomized and quasi-randomized controlled trials of operative treatment for chronic lateral ankle instability were included. Two review authors independently extracted data from each study and assessed risk of bias. Where appropriate, results of comparable studies were pooled.

Results: Seven randomized controlled trials were included for analysis. They fell in five clearly distinct groups. One study comparing two different kinds of non-anatomic reconstruction procedures (dynamic and static tenodesis) found two clinical outcomes favoring static tenodesis: better clinical satisfaction and fewer subsequent sprains. Two studies compared non-anatomic reconstruction versus anatomic repairment. In one study, nerve damage was more frequent in non-anatomic reconstruction group; the other one reported that radiological measurement of ankle laxity showed that non-anatomic reconstruction provided higher reduction of talar tilt angle. Two studies comparing two anatomic repairment surgical techniques (transosseous suture versus imbrication) showed no significant difference in any clinical outcome at the follow-up except operation time. One study compared two different anatomic repairment techniques. They found that the double anchor technique was superior with respect to the reduction of talar tilt than single anchor technique. One study compared an anatomic reconstruction procedure with a modified Brostrom technique. Primary reconstruction combined with ligament advanced reinforcement system results in better patient-scored clinical outcome, at 2 years post-surgery, than the modified Brostrom procedure.

Conclusions: There is limited evidence to support any one surgical technique over another surgical technique for chronic lateral ankle instability, but based on the evidence, we could still get some conclusions: (1) There are limitations to the use of dynamic tenodesis, which obtained poor clinical satisfaction and more subsequent sprains. (2) Non-anatomic reconstruction abnormally increased inversion stiffness at the subtalar level as compare with anatomic repairment. (3) Multiple types of modified Brostrom procedures could acquire good clinical results. (4) Anatomic reconstruction is a better procedure for some specific patients.

Keywords: Ankle instability; Ankle sprain; Lateral ligament injury; Meta-analysis; Surgical treatment.

Fig. 1

PRISMA 2009 flow diagram

Fig. 2

Risk of bias summary: review authors’ judgments about each risk of bias item for each included study

Fig. 3

Risk of bias graph: review authors’ judgments about each risk of bias item presented as percentages across all included studies

Fig. 4

Forest plot of comparison: 1 non-anatomic reconstruction (static tenodesis) versus non-anatomic reconstruction (dynamic tenodesis), outcome: 1.1 satisfaction at 25 months

Fig. 5

Forest plot of comparison: 1 non-anatomic reconstruction (static tenodesis) versus non-anatomic reconstruction (dynamic tenodesis), outcome: 1.2 complications

Fig. 6

Forest plot of comparison: 2 non-anatomic reconstruction (Evans/CS) versus anatomic repairment (MB), outcome: 2.1 subjective instability, pain, and swelling

Fig. 7

Forest plot of comparison: 2 non-anatomic reconstruction (Evans/CS) versus anatomic repairment (MB), outcome: 2.2 radiographic instability

Fig. 8

Forest plot of comparison: 2 non-anatomic reconstruction (Evans/CS) versus anatomic repairment (MB), outcome: 2.3 complications

Fig. 9

Forest plot of comparison: 2 non-anatomic reconstruction (Evans/CS) versus anatomic repairment (MB), outcome: 2.4 reduction in measures of radiographic ligament laxity

Fig. 10

Forest plot of comparison: 3 anatomic repairment (transosseous suture, MB) versus anatomic repairment (imbrication, MB), outcome: 3.1 operating time (minutes)

Fig. 11

Forest plot of comparison: 3 anatomic repairment (transosseous suture, MB) versus anatomic repairment (imbrication, MB), outcome: 3.2 satisfaction at > 24 months

Fig. 12

Forest plot of comparison: 3 anatomic repairment (transosseous suture, MB) versus anatomic repairment (imbrication, MB), outcome: 3.3 subjective instability, pain, and activity

Fig. 13

Forest plot of comparison: 3 anatomic repairment (transosseous suture, MB) versus anatomic repairment (imbrication, MB), outcome: 3.4 talar tilt angle (degrees)

Fig. 14

Forest plot of comparison: 3 anatomic repairment (transosseous suture, MB) versus anatomic repairment (imbrication, MB), outcome: 3.5 anterior talar translation (millimeters)

Fig. 15

Forest plot of comparison: 3 anatomic repairment (transosseous suture, MB) versus anatomic repairment (imbrication, MB), outcome: 3.6 complications

Fig. 16

Forest plot of comparison: 4 anatomic repairment (single anchor, MB) versus anatomic repairment (double anchor, MB), outcome:4.1 Karlsson score

Fig. 17

Forest plot of comparison: 4 anatomic repairment (single anchor, MB) versus anatomic repairment (double anchor, MB), outcome: 4.2 satisfaction at > 24 months

Fig. 18

Forest plot of comparison: 4 anatomic repairment (single anchor, MB) versus anatomic repairment (double anchor, MB), outcome: 4.3 complications

Fig. 19

Forest plot of comparison: 4 anatomic repairment (single anchor, MB) versus anatomic repairment (double anchor, MB), outcome: 4.4 reduction in measures of radiographic ligament laxity

Fig. 20

Forest plot of comparison: 5 anatomic reconstruction (LARS) versus anatomic repairment (MB), outcome: 5.1 FAOS. LARS ligament advanced reinforcement system, MB modified Brostrom procedure

Fig. 21

Forest plot of comparison: 5 anatomic reconstruction (LARS) versus anatomic repairment (MB), outcome: 5.2 complications. LARS ligament advanced reinforcement system, MB modified Brostrom procedure