Perspectives on Ligament Augmentation Techniques Among AOFAS Members: A Cross-Sectional Survey

Abstract

Background: Ligamentous pathologies and injuries of the foot and ankle commonly require surgical repair. Ligament augmentation techniques (LAT) use a synthetic ligament that spans the anatomic length of the injured ligament, anchoring to bone on both ends. Use of LAT in foot and ankle surgery is rapidly progressing, but the rates of usage and surgeon-specific indications are not well known. This study aims to provide an in-depth analysis of LAT use by foot and ankle surgeons.

Methods: An online survey was distributed to the surgeon members of the American Orthopaedic Foot & Ankle Society (AOFAS). Survey questions detailed demographics and practice details, current use of LATs, and the future trajectory of LATs. Responses were tabulated and summarized. Logistic regression and χ2 tests of independence compared trends in LAT use between North America and outside continent, years in practice, and type of practice.

Results: Of 1895 invited surgeons, 244 (12.9%) completed the survey. Among respondents, 209 surgeons (85.7%) reported current LAT use, most of whom were based in North America (197, 80.7%). North American respondents were significantly more likely to report using LAT when compared to respondents outside of North America (89% vs 72% respectively) (P = .007). The 3 most common ligaments for LAT use were the ATFL (205, 98.1%) followed by the syndesmosis ligament (125, 59.8%) and the deltoid ligament (122, 58.4%). The most common reason for LAT use was faster return to sport (136, 65.1%). More than half of respondents (131, 53.6%) anticipate increased LAT in the future.

Conclusion: LAT use in foot and ankle surgery is multifactorial, influenced by patient demographics, regional practices, industry dynamics, and surgeon training. Ongoing debates about the cost-effectiveness and long-term outcomes of LAT suggest that further research is necessary to fully define its role in orthopaedic foot and ankle surgery.

Level of evidence: Level V, therapeutic.

Keywords: flexible fixation; ligament augmentation; ligament repair.

Visual Abstract

This is a visual representation of the abstract.

Figure 1.

The percentage of surgeons that use ligament augmentation techniques for their foot and ankle surgeries by (A) continent and (B) geographic regions within the United States. Values within each bar indicate the frequency of responses.

Figure 2.

The distributions of the percentage of surgeons using ligament augmentation technique on (A) the anterior talofibular ligament, (B) the syndesmosis ligament, and (C) the deltoid ligament.

Figure 3.

Reasons that foot and ankle surgeons are using ligament augmentation techniques. Proportions represented for each reason are among the 209 surgeons who perform ligament augmentation techniques in their practice. Common “other” responses included revision surgery (n = 17), ligamentous laxity (n = 16), and poor soft tissues (n = 10).

Figure 4.

Patient characteristics that influence the use or non-use of ligament augmentation techniques. Respondents could select any of the listed factors, or “none.” Following selection of a characteristic, respondents were prompted to provide the degree of influence that each selected characteristic has on a 7-point Likert scale.

Figure 5.

Level of concern surgeons have about the cost of ligament augmentation techniques to their practice.

Figure 6.

Trajectory of ligament augmentation techniques (LATs) in foot and ankle surgery 5 years in the future, with tabulated reasons for increased, decreased, or same use of LATs.