Systematic Review
Arthroscopic Repair of Lateral Ankle Ligament Complex by Suture Anchor Jingwei Wang, M.Sc., Yinghui Hua, Ph.D., Shiyi Chen, Ph.D., Hongyun Li, Ph.D., Jian Zhang, M.Sc., and Yunxia Li, Ph.D.
Purpose: Arthroscopic repair of the lateral ligament complex with suture anchors is increasingly used to treat chronic ankle instability (CAI). Our aims are (1) to analyze and evaluate the literature on arthroscopic suture anchor repair of the anterior talofibular ligament and (2) to conduct a systematic review of the clinical evidence on the reported outcomes and complications of treating CAI with this technique. Methods: We performed a systematic review of the literature using PubMed, Ovid, Elsevier ScienceDirect, Web of ScienceeConference Proceedings Citation Index, and the Cochrane Database of Systematic Reviews from 1987 to September 2013. Clinical studies using the arthroscopic suture anchor technique to treat CAI were included. Outcome measures consisted of clinical assessment of postoperative ligament stability and complications. In addition, the methodologic quality of the included studies was assessed by use of the modified Coleman Methodology Score. Results: After reviewing 371 studies, we identified 6 studies (5 retrospective case series and 1 prospective case series, all Level IV) that met the inclusion criteria, with a mean Coleman Methodology Score of 71.8 7.52 (range, 63 to 82). In these studies 178 patients (179 ankles) underwent arthroscopic suture anchor repair of the anterior talofibular ligament with a mean follow-up period of 38.9 months (range, 6 to 117.6 months). All patients were reported to have subjective improvement of their ankle instability, with complications in 31 cases. Conclusions: Studies of arthroscopic suture anchor technique to treat CAI are sparse, with moderate mean methodologic quality. The included studies suggest that the arthroscopic technique is a feasible procedure to restore ankle stability; however, on the basis of our review, this technique seems to be associated with a relatively high complication rate. Extensive cadaveric studies, clinical trials, and comparative studies comparing arthroscopic and open repair should be performed in the future. Level of Evidence: Level IV, systematic review of Level IV studies.
L
ateral ankle sprain is one of the most frequently encountered sports injuries.1,2 The basic mechanism of injury in lateral ankle sprains is excessive plantar flexion and inversion of the ankle, and the most commonly injured ligament is the anterior talofibular ligament (ATFL), followed by the calcaneofibular ligament (CFL). Most patients with acute ankle sprains can be successfully managed with conservative treatment, such
From the Department of Sports Medicine and Arthroscopy Surgery, Sports Medicine Center of Fudan University, Huashan Hospital, Shanghai, China. The authors report the following potential conflict of interest or source of funding: J.W., Y.H., S.C., H.L., J.Z., and Y.L. receive support from Sports Medicine Center of Fudan University. This work was supported by the National Natural Science Foundation of China (NSFC81101391). Received December 9, 2013; accepted February 14, 2014. Address correspondence to Yinghui Hua, Ph.D., Department of Sports Medicine and Arthroscopy Surgery, Sports Medicine Center of Fudan University, Huashan Hospital, Fudan University, No. 12 Urumq Middle Road, Shanghai, China 20040. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/13861/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.02.023
as bracing and physical therapy.3 However, chronic instability is reported to occur in 20% to 40% of sprains, with a reinjury rate as high as 80%.4-7 If residual instability persists after a solid course of nonoperative treatment, the patient should be offered surgical options to restore ankle stability.3,8 Many surgical techniques have been described for the treatment of chronic lateral ankle instability. These can be divided into anatomic repair, nonanatomic reconstruction, and anatomic reconstruction. Many reports have noted that the anatomic repair technique is generally preferred over reconstructive procedures.9-13 Numerous studies have shown good to excellent results with anatomic repair, with more than 85% of patients achieving good outcomes.12,14-16 Broström17 originally described anatomic repair of the lateral ligaments of the ankle as either direct repair after an intrasubstance injury or repair of the ligaments to their anatomic origins on the fibula with bone tunnels for avulsion injuries. Gould et al.18 later modified this technique by augmenting the repair with the inferior extensor retinaculum. This modified procedure has become the gold standard for anatomic repair techniques.19,20
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol
-,
No
-
(Month), 2014: pp 1-8
1
2
J. WANG ET AL.
considered. Not only studies in print journals but also electronically published articles and conference records were deemed as eligible for analysis and investigation. All references within the included articles were manually cross-referenced for potential inclusion to ensure that they were not missed in the initial search. Specific inclusion and exclusion criteria were applied to identify clinical studies that included preoperative conditions, postoperative outcomes, and complications. The articles were selected by the first 2 authors separately, and then, the selected articles were discussed together. If there was any disagreement, the subject was discussed until agreement was achieved. Figure 1 shows the process of searching, screening, identification, and inclusion. Inclusion Criteria The inclusion criteria for clinical articles were as follows: 1. English language 2. Clinical study using arthroscopic suture anchor technique 3. Preoperative conditions reported: both subjective and objective 4. Postoperative outcomes reported: both clinical and functional 5. Postoperative complications reported 6. Length of follow-up reported 7. Description of rehabilitation included 8. Level of Evidence from I to IV
Fig 1. Flowchart of search methods.
The arthroscopic technique is increasingly used to repair the lateral ligament complex of the ankle. On the basis of current studies of arthroscopic treatment of chronic ankle instability resulting from ATFL injury, we performed a literature review to investigate the outcomes of this technique and evaluate whether it can yield good outcomes in the treatment of chronic ankle instability with fewer complications.
Exclusion Criteria The exclusive criteria for clinical articles were as follows: 1. Non-English language 2. Failure to describe postoperative clinical or functional outcomes 3. Reports of surgical reconstructive procedures other than repair of ATFL 4. Articles describing arthroscopic thermal shrinkage technique to treat chronic lateral instability 5. Basic science studies, cadaveric studies, and anatomic and pathologic studies, as well as other reviews, letters to the editor, and expert opinions
Methods We performed a systematic review of the literature using multiple medical databases, including PubMed, Ovid, Elsevier ScienceDirect, Web of ScienceeConference Proceedings Citation Index, and the Cochrane Database of Systematic Reviews, for studies published between 1987 and September 2013. The search was performed separately and independently by the first 2 authors, using the following key words: arthroscopic, ankle instability, Broström, anterior talofibular ligament, and suture anchor. Articles with Level I, II, III, or IV Evidence were
Data Extraction and Analysis Data extraction and analysis were conducted by all authors separately and were then synthesized by the senior author. Relevant data included the following: authors; sample size; preoperative conditions (gender, age, time from injury to surgery, subjective feelings of instability, objective tests, and American Orthopaedic Foot & Ankle Society [AOFAS] score); postoperative outcomes including clinical (subjective improvement in ankle stability, objective tests, AOFAS score, and
3
SYSTEMATIC REVIEW OF SUTURE ANCHOR REPAIR Table 1. Summary of Outcomes in Studies Author James and Ryan2 Jordi et al.3 Kim et al.6 Corte-Real and Moreira22 Acevedo and Mangone23 Caio et al.24
Year 2013 2013 2011 2009
No. of Patients (No. of Ankles) 40 16 28 31
2011
23 (24)
2011
40
Age (yr) 45.6 (15-83) 29.3 (17-46) 38.6 (22-55) 33.3 (15-54) 39 (15-55) 28.8 (15-53)
Male/ Female 13/27 10/6 6/22 19/9
Follow-Up (mo) 12.13 4.27 (6-21) 22.3 (12-35) 15.9 (13-25) 27.5 (6-48)
Time From Injury to Surgery (mo) NR NR 16.8 (7-36) 7 (2-30)
Preoperative AOFAS Score 41.2 (23-64) 67 (59-77) 60.78 16.38 NR
Postoperative AOFAS Score 95.4 (84-100) 97 (95-100) 92.48 6.14 85.3 (65-100)
14/9
10.9
NR
NR
NR
24/14
117.6 (9.8 yr)
9 (6-19)
NR
90 (44-100)
NR, not reported.
radiographic findings) and functional outcomes; and postoperative complications. All data on complications were collected, and other intra-articular findings and types of management were also analyzed. Given the design heterogeneity of the included studies, a meta-analysis was considered inappropriate; thus no statistical comparison was made. Instead, comprehensive and specific descriptions of the studies and their conclusions were provided. The analysis was performed with Excel 2011 (Microsoft, Redmond, WA) and Stata processing software (version 12.0; StataCorp, College Station, TX). Quality Assessment All authors assessed the methodologic quality of each included study separately, according to the modified Coleman Methodology Score (CMS). The CMS is a 10criteria validated scoring system assessing the methodologic quality of scientific studies, with a final score ranging from 0 to 100. A perfect score of 100 represents a study design that largely avoids the influence of chance, various biases, and confounding factors.21 If a difference of more than 3 points existed among the authors’ results, we re-evaluated and discussed the findings until agreement was achieved.
Results Literature Review Our initial search returned 371 studies. After application of the inclusion criteria, 35 clinical studies remained. Of these 35 studies, 29 were excluded because they used reconstructive procedures or thermal shrinkage techniques; they were basic science, cadaveric, anatomic, or pathologic studies; or they failed to describe postoperative clinical or functional outcomes. Six clinical studies ultimately met our inclusion criteria.2,3,6,22-24 Data Extraction The Level of Evidence of the 6 included studies was Level IV, including 5 retrospective case series and 1 prospective case series. The included clinical studies described 178 patients (179 ankles) who underwent arthroscopic repair of the ATFL with the suture anchor
technique. All studies clearly stated the length of followup, with a mean of 38.9 months (range, 6 to 117.6 months). Postoperative AOFAS scores were reported in 5 studies, 3 of which included preoperative AOFAS scores. The range of postoperative AOFAS scores was 44 to 100. James and Ryan2 also used other evaluation measures to estimate postoperative outcomes, including preoperative visual analog scale (VAS) scores (mean, 8.2; range, 4 to 10), postoperative VAS scores (mean, 1.1; range, 0 to 5), and postoperative Karlsson-Peterson scores (mean, 93.6; range, 82 to 100). Three articles reported the time from injury to surgery, with a mean interval of 10.9 months (range, 6 to 36 months).6,22,24 One study noted that the mean time to return to full activity was 20.2 weeks (range, 12 to 42 weeks).2 In the study by Corte-Real and Moreira,22 the mean patient satisfaction score was 3.8 (range, 1 to 5). All patients in the included studies showed subjective improvement of their ankle instability. Five studies reported improvement in the AOFAS scores.2,3,6,22,24 No patients required reoperation. More details from the included articles are provided in Table 1. Complications Complications were reported in 31 cases among the 179 ankles undergoing arthroscopic repair of the ATFL with the suture anchor technique. The complication rate for each study is shown in Table 2. The types of complications included portal-site irritation in 4 patients; delayed wound healing in 4; nerve complications in 5, comprising neuritis of the intermediate dorsal cutaneous nerve in 1, superficial peroneal nerve numbness in 3 (1 persistent), and sural nerve neuritis in 1; additional acute ankle sprain in 4; superficial infection in 2; deep venous thrombosis in 2; and peroneal tendonitis in 1. Prominent asymptomatic suture knots under the skin were reported by Kim et al.6 in 3 cases and Corte-Real and Moreira22 in 4 cases. Acevedo and Mangone23 described 1 patient in whom neurologic problems developed 12 months postoperatively but were considered unrelated to the treatment. Kim et al.6 reported 2 additional cases of acute ankle sprain after surgery, and 1 patient had a distal fibular fracture during the postoperative period in the study of
4
J. WANG ET AL.
Table 2. Types of Complications in Each Study No. of Patients (No. of Ankles) 40
Author James and Ryan2
Jordi et al.3
16
Kim et al.6
28
Corte-Real and Moreira22
31
Acevedo and Mangone23
23 (24)
Caio et al.24
40
Complication Type (No.) Deep venous thrombosis (1) Neuritis of intermediate dorsal cutaneous nerve (1) Distal fibular fracture (1) Delayed wound healing (1) Superficial infection (1) Portal-site irritation (4) Superficial infection (1) Prominent asymptomatic suture knots (3) Additional acute ankle sprain (2) Delayed wound healing (3) Superficial peroneal nerve numbness (3 [1 persistent]) Additional acute ankle sprain (2) Deep venous thrombosis (1) Prominent asymptomatic suture knots (4) Peroneal tendonitis (1) Sural nerve neuritis (1) Neurologic problems 12 mo postoperatively (1) 0
James and Ryan.2 The authors noted that these 3 cases were unrelated to surgery; however, they seemed to be associated with severe morbidity postoperatively, especially with such short times to follow-up, so we defined them as major complications. More details on the complications in each study are shown in Table 2. Intra-articular Findings We also reviewed information on intra-articular lesion status. All the studies described the concomitant intra-articular pathologic features and their treatment. The majority of findings comprised synovitis, loose bodies, osteochondral lesions, anterior spurs, and anterior soft-tissue impingement. We consider the occurrence of intra-articular lesions to be high. All of these findings were managed during the procedure. Methodologic Quality Assessment The mean modified CMS was 71.8 7.52 (range, 63 to 82) for all included articles. The overall CMS for each criterion and the mean CMS in each study are shown in Tables 3 and 4, respectively.
Discussion Anatomic repair of the lateral ligament complex of the ankle based on the Broström procedure is usually the first choice of treatment for chronic ankle instability.4,17,25 The arthroscopic technique has increasingly been used in recent years because of its obvious advantages as a minimally invasive method. Arthroscopic repair was first described by Hawkins,26 who placed a staple on the talus to plicate the talofibular ligament. He reported a series of 25 patients with good results; however, the prominent staples had caused patients some discomfort. Surgeons have modified the technique
Total No. of Complications 3
Complication Rate 7.5%
2
12.5%
10
35.7%
13
41.9%
3
12.5%
0
0%
progressively. After the enthusiasm generated by the treatment of shoulder instability with thermal capsular shrinkage, a similar method was used in the ankle to tighten lax lateral ligaments.22 Some studies reported good subjective outcome results.27-30 However, the lack of significant improvement in mechanical stability is the most obvious shortcoming of this technique. A suture anchor technique was later developed to address problems such as discomfort caused by prominent staples or mechanical instability with the shrinkage technique, and relatively high success rates have been obtained. The method has been increasingly applied to restore ankle stability by attaching the ATFL to the fibula and/or talus to reconstruct the lateral ligament complex of the ankle. A cadaveric study performed by Giza et al.20 showed that arthroscopic anatomic repair of the lateral ligaments of the ankle could achieve comparable biomechanical results to open procedures. In all of the studies we reviewed, the suture anchor was placed in the fibula to repair the ATFL. Some also attached the inferior extensor retinaculum to the periosteum of the fibula to Table 3. Overall CMS Score for Each Criterion Criteria (Maximum Score) Part A Study size (10) Mean follow-up, mo (5) No. of procedures (10) Type of study (15) Diagnostic certainty (5) Surgery description (5) Rehabilitation description (10) Part B Outcome criteria (10) Procedure for outcomes (15) Selection process (15) Total score (100)
Mean
SD
Range
3.33 2.67 10 1.67 5 5 10
1.63 1.97 0 4.08 0 0 0
0-4 0-5 10 0-10 5 5 10
10 11.7 12.5 71.8
0 1.63 2.74 7.52
10 11 10-15 63-82
Study Size 4 0 4 4 4 4 Publication Year 2013 2013 2011 2009 2011 2011 Author James and Ryan2 Jordi et al.3 Kim et al.6 Corte-Real and Moreira22 Acevedo and Mangone23 Caio et al.24
Table 4. Detailed CMS Scores for Each Study
Mean Follow-Up (mo) 2 2 2 5 0 5
No. of Procedures 10 10 10 10 10 10
Type of Study 10 0 0 0 0 0
Diagnostic Certainty 5 5 5 5 5 5
Surgery Description 5 5 5 5 5 5
Rehabilitation Description 10 10 10 10 10 10
Outcome Criteria 10 10 10 10 10 10
Procedure for Outcome 11 11 11 11 11 15
Selection Process 15 10 15 10 10 15
Total Score 82 63 72 70 65 79
SYSTEMATIC REVIEW OF SUTURE ANCHOR REPAIR
5
reinforce the repair.18,24 CFL repair was not performed. James and Ryan2 indicated that direct ATFL repair without CFL repair can result in good to excellent postoperative outcomes. Jordi et al.3 described a “knotless suture anchor” technique to avoid the discomfort or pain caused by a prominent suture knot. Although arthroscopic suture anchor repair of the ATFL to treat chronic ankle instability is evolving rapidly, a high rate of complications (5.3% to 29%) has been described in many case series according to Jordi et al.3 With the exception of Caio et al.,24 who reported that no patient had wound dehiscence and/or infection, paresthesia, or numbness and there was no marked limitation in eversion and inversion after the operation at 9.8 years’ follow-up, all the other studies in our review showed relatively high complication rates (from 7.5% to 41.9%). Neuritis of the superficial peroneal or sural nerve and pain or discomfort resulting from a prominent anchor or suture knot are frequently reported complications.3,6,22,23 To mitigate the risk of nerve damage caused by the arthroscopic technique, especially to avoid neuritis of the superficial peroneal and sural nerves, surgeons must have good arthroscopic skills and a thorough knowledge of foot and ankle anatomy. Jordi et al.3 in their study also recommended caution on the part of the surgeon when creating portals, introducing instruments, and using instruments to reduce the risk of nerve injuries. Postoperative ligament stability is evaluated by clinical examination. With open surgery and delayed primary ligament repair, subjective residual instability has been reported in 5% to 12% of patients.31-35 There were some positive findings in the studies we reviewed: Caio et al.24 reported that the postoperative anterior drawer test showed grade 0 laxity in 25 patients and grade 1 laxity in 13 patients; in the study performed by Kim et al.,6 3 patients showed laxity on postoperative stress radiographs, with more than 3 mm of displacement compared with the contralateral side. Most of the patients reported obvious subjective improvement in their ankle stability and were able to return to their preinjury activity level, indicating that mechanical instability and functional instability are not necessarily closely related. We also collected data on instability recurrence. Kim et al.6 and Corte-Real and Moreira22 both reported 2 cases of additional acute ankle sprain; the follow-up stress radiographs in these patients did not show any mechanical instability, and all were treated conservatively and returned to their postoperative status. Some studies describing acute and delayed open ligament repair have reported the incidence of postoperative stiffness.33,36-38 A study by Hennrikus et al.32 found that 9% of patients who underwent the open Broström procedure thought the repair was too tight, as compared with 28% of patients who underwent the tenodesis procedure. In the studies
6
J. WANG ET AL.
we reviewed, no cases of stiffness were reported. Future research is required to critically evaluate whether the arthroscopic technique effectively prevents stiffness and morbidity. Whether to manage intra-articular lesions during surgery is controversial. Ankle instability is frequently accompanied by intra-articular lesions,6,7,39 including osteochondral lesions, synovitis, loose bodies, anterior spurs, and anterior soft-tissue impingement. During the arthroscopic procedure, concomitant intra-articular injuries can be evaluated and treated before ligament repair. A study by Ferkel and Chams7 suggested that chondral lesions did not influence the outcome of the procedure. However, no comparison was performed between patients with and without chondral lesions, so their conclusion needs further consideration. Many reports have indicated that concomitant intra-articular injuries might be associated with postoperative rehabilitation results and patients’ subjective feelings. Intraarticular osteochondral lesions of the talus have been considered the strongest predictors of poor clinical outcomes. In several studies researchers found a significant association between chondral injury and postoperative ankle pain. Patients with osteochondral lesions were more likely to express dissatisfaction than patients without these lesions.24,25,40,41 For this reason, arthroscopic investigation and management of the joint are performed before many authors perform the procedure. Hua et al.25 suggested that performing ankle arthroscopy to treat intra-articular injuries is a safe procedure for the treatment of patients with chronic ankle instability and produced satisfactory surgical outcomes. In this review, all the authors treated intraarticular lesions before ligament repair and no patient reported subjective dissatisfaction after surgery. Certain benefits can be obtained from arthroscopic treatment; for example, it allows direct visualization of intra-articular structures without an extensive surgical approach, and it allows for stress testing and evaluation of the competency of the ligamentous structures surrounding the ankle in cases of joint laxity.42 Because of smaller incisions, patients may quickly return to normal activity levels. In addition, the arthroscopic approach can be easily converted to open surgery if necessary. On the other hand, the arthroscopic procedure has some disadvantages, such as the risk of complications, high surgical equipment and technique needs, and a steep learning curve. Limitations The level of evidence of this study is relatively low, and the methodologic quality is moderate. Given the design heterogeneity of the included studies, we were unable to perform a meta-analysis; thus no statistical comparison was made. The sample size of all included studies was small, the study population was
heterogeneous, and all but 1 study included a single cohort. There were no direct comparisons between the described approach and other techniques (e.g., an open procedure). The studies were not randomized or comparative case series, which can result in biases, including selection bias and performance bias. The postoperative outcomes were divided into 2 main componentsdthe subjective evaluation of the patient and the objective findings of the authorsdwhich could allow physician bias to influence the results. In addition, not every study noted patient satisfaction during follow-up, and there was a large variation in follow-up time among studies (range, 6 to 117.6 months). These variations could result in less valid measurements of general long-term postoperative outcomes. Some of the included studies provided insufficient information. Instability was not quantified preoperatively and postoperatively in all studies. Lateral ligament disruption of the ankle is generally diagnosed by stress radiography. However, this method provides only a mechanical assessment of ankle stability under a limited stress force, which may be less than the actual tensile force on the ligaments during sports or other strenuous activities.3 Most of the studies used AOFAS scores to estimate the patients’ preoperative condition and postoperative outcome. Although other evaluation standards exist, such as VAS and Karlsson-Peterson scores, not all the studies used these tools to estimate the postoperative outcomes. This review contains no protocol for arthroscopic suture anchor repair of the lateral ligament ankle complex to treat CAI, which may lead to reporting bias. Extensive cadaveric and clinical studies, as well as comparisons with other procedures, should be performed to compensate for the weaknesses of existing studies.
Conclusions After a full-scale investigation and evaluation of existing studies, considering the patients’ subjective feelings, postoperative outcomes, and physical examination findings, we deem that even though arthroscopic repair of the lateral ligament complex with the suture anchor technique can restore ankle stability, the risk of complications is among the main considerations based on current evidence. Extensive cadaveric studies, clinical trials, and comparative studies comparing arthroscopic and open repair should be performed in the future to further evaluate the efficacy of arthroscopic treatment.
References 1. Colville M. Surgical treatment of the unstable ankle. J Am Acad Orthop Surg 1998;6:368-377. 2. James C, Ryan R. The “all inside” arthroscopic Broström procedure: A prospective study of 40 consecutive patients. J Foot Ankle Surg 2013;52:568-574.
SYSTEMATIC REVIEW OF SUTURE ANCHOR REPAIR 3. Jordi V, Pau G, Alexandro P, Eduard R, Fernando P. Allinside arthroscopic lateral collateral repair for ankle instability with a knotless suture anchor technique. Ankle Foot Int 2013;34:1701-1709. 4. Baumhauer JF, O’Brien T. Surgical considerations in the treatment of ankle instability. J Athl Train 2002;37:458-462. 5. Boardman DL, Liu SH. Contribution of the anterolateral joint capsule to the mechanical stability of the ankle. Clin Orthop Relat Res 1997;(341):224-232. 6. Kim ES, Lee TK, Park JS, Lee YK. Arthroscopic anterior talofibular ligament repair for chronic ankle instability with a suture anchor technique. Orthopedics 2011;34:273. 7. Ferkel RD, Chams RN. Chronic lateral instability: Arthroscopic findings and long-term results. Foot Ankle Int 2007;28:24-31. 8. Karlsson J, Lansinger O. Lateral instability of the ankle joint. Clin Orthop Relat Res 1992;(276):253-261. 9. Bahr R, Pena R, Shine J, Lew WD, Tyrdal S, Engebretsen L. Biomechanics of ankle ligament reconstruction: An in vitro comparison of the Broström repair, Watson-Jones reconstruction, and a new anatomic reconstruction technique. Am J Sports Med 1997;25:424-432. 10. Fujii T, Kitaoka HB, Watanabe K, Luo ZP, An KN. Comparison of modified Broström and Evans procedures in simulated lateral ankle injury. Med Sci Sports Exerc 2006;38:1025-1031. 11. Hollis JM, Blasier RD, Flahiff CM, Hofmann OE. Biomechanical comparison of constructive techniques in simulated lateral ankle ligament injury. Am J Sports Med 1955;23:678-682. 12. Krips R, van Dijk CN, Halasi PT, et al. Long-term outcome of anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: A multicenter study. Foot Ankle Int 2001;22:415-421. 13. Liu SH, Baker CL. Comparison of lateral ankle ligamentous reconstruction procedures. Am J Sports Med 1994;22: 313-317. 14. Hamilton WG, Thompson FM, Snow SW. The modified Broström procedure for lateral ankle instability. Foot Ankle 1993;14:1-7. 15. Bell SJ, Mologne TS, Sitler DF, Cox JS. Twenty-six-year results after Broström procedure for chronic lateral ankle instability. Am J Sports Med 2006;34:975-978. 16. Thermann H, Zwipp H, Tscerne H. Treatment algorithm of chronic ankle and subtalar instability. Foot Ankle Int 1997;18:163-169. 17. Broström L. Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures. Acta Chir Scand 1966;132: 551-565. 18. Gould N, Seligson D, Gassman J. Early and late repair of lateral ligament of the ankle. Foot Ankle 1980;1:84-89. 19. Brodsky AR, O’Malley MJ, Bohne WH, Deland JA, Kennedy JG. An analysis of outcome measures following the Broström-Gould procedure for chronic lateral ankle instability. Foot Ankle Int 2005;26:816-819. 20. Giza E, Shin EC, Wong SE, et al. Arthroscopic suture anchor repair of the lateral ligament ankle complex: A cadaveric study. Am J Sports Med 2013;41:2567-2572. 21. Coleman BD, Khan KM, Maffulli N, Cook JL, Walk JD. Studies of surgical outcome after patellar tendinopathy: Clinical significance of methodologic deficiencies and
22. 23. 24.
25.
26. 27.
28.
29.
30.
31. 32.
33.
34.
35. 36.
37.
38.
39.
7
guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports 2000;10:2-11. Corte-Real N, Moreira R. Arthroscopic repair of chronic lateral ankle instability. Foot Ankle Int 2009;30:213-217. Acevedo J, Mangone P. Arthroscopic lateral ankle ligament reconstruction. Tech Foot Ankle Surg 2011;10:111-116. Caio N, Fernando R, Angelo B, Inacio A, Moises C, Nicola M. Arthroscopic-assisted Broström-Gould for chronic ankle instability: A long-term follow-up. Am J Sports Med 2011;39:2381-2388. Hua YH, Chen SY, Li YX, Chen JW, Li H. Combination of modified Broström procedure with ankle arthroscopy for chronic ankle instability accompanied by intra-articular symptoms. Arthroscopy 2010;26:524-528. Hawkins RB. Arthroscopic stapling repair for chronic lateral instability. Clin Podiatr Med Surg 1987;4:875-883. Maiotti M, Massoni C, Tarantino U. The use of arthroscopic thermal shrinkage to treat chronic lateral ankle instability in young athletes. Arthroscopy 2005;21:751-757. Oloff LM, Bocko AP, Fanton G. Arthroscopic monopolar radiofrequency thermal stabilization for chronic lateral ankle instability: A preliminary report on 10 cases. J Foot Ankle Surg 2000;39:144-153. Berlet GC, Saar WE, Ryan A, Lee TH. Thermal-assisted capsular modification for functional ankle instability. Foot Ankle Clin 2002;7:567-576. de Vries JS, Krips R, Blankevoort L, Fievez AW, van Dijk CN. Arthroscopic capsular shrinkage for chronic ankle instability with thermal radiofrequency: Prospective multicenter trial. Orthopedics 2008;31:655. Sammarco VJ. Complications of lateral ankle ligament reconstruction. Clin Orthop Relat Res 2001;(391):123-132. Hennrikus WL, Mapes RC, Lyons PM, Lapoint JM. Outcomes of the Chrisman-Snook and modified-Broström procedures for chronic lateral ankle instability: A prospective, randomized comparison. Am J Sports Med 1996;24:400-404. Karlsson J, Bergsten T, Lansinger O, Peterson L. Surgical treatment of chronic lateral instability of the ankle joint: A new procedure. Am J Sports Med 1989;17:268-274. Karlsson J, Eriksson BI, Bergsten T, Rudholm O, Swärd L. Comparison of two anatomic reconstructions for chronic lateral instability of the ankle joint. Am J Sports Med 1997;25:48-53. Liu SH, Jacobson KE. A new operation for chronic lateral ankle instability. J Bone Joint Surg Br 1995;77:55-59. Cass JR, Morrey BF, Katoh Y, Chao EY. Ankle instability: Comparison of primary repair and delayed reconstruction after long-term follow-up study. Clin Orthop Relat Res 1985;(198):110-117. Kitaoka HB, Lee MD, Morrey BF, Cass JR. Acute repair and delayed reconstruction for lateral ankle instability: Twenty-year follow-up study. J Orthop Trauma 1997;11: 530-535. Rudert M, Wulker N, Wirth CJ. Reconstruction of the lateral ligaments of the ankle using a regional periosteal flap. J Bone Joint Surg Br 1997;79:446-451. Okuda R, Kinoshita M, Morikawa J, Yasuda T, Abe M. Arthroscopic findings in chronic lateral ankle instability: Do focal chondral lesions influence the results of ligament reconstruction? Am J Sports Med 2005;33:35-42.
8
J. WANG ET AL.
40. Choi WJ, Lee JW, Han SH, Kim BS, Lee SK. Chronic lateral ankle instability: The effect of intra-articular lesions on clinical outcome. Am J Sports Med 2008;36:2167-2172. 41. Takahashi T, Nakahira M, Kaho K, Kawakami T. Anatomical reconstruction of chronic lateral ligament
injury of the ankle using pedicle tendon of the extensor digitorum longus. Arch Orthop Trauma Surg 2003;123: 175-179. 42. Ferkel RD, Small HN, Gittins JE. Complications in foot and ankle arthroscopy. Clin Orthop Relat Res 2001;391:89-104.
Arthroscopic Repair of Lateral Ankle Ligament Complex by Suture Anchor Jingwei Wang, M.Sc., Yinghui Hua, Ph.D., Shiyi Chen, Ph.D., Hongyun Li, Ph.D., Jian Zhang, M.Sc., and Yunxia Li, Ph.D.
Purpose: Arthroscopic repair of the lateral ligament complex with suture anchors is increasingly used to treat chronic ankle instability (CAI). Our aims are (1) to analyze and evaluate the literature on arthroscopic suture anchor repair of the anterior talofibular ligament and (2) to conduct a systematic review of the clinical evidence on the reported outcomes and complications of treating CAI with this technique. Methods: We performed a systematic review of the literature using PubMed, Ovid, Elsevier ScienceDirect, Web of ScienceeConference Proceedings Citation Index, and the Cochrane Database of Systematic Reviews from 1987 to September 2013. Clinical studies using the arthroscopic suture anchor technique to treat CAI were included. Outcome measures consisted of clinical assessment of postoperative ligament stability and complications. In addition, the methodologic quality of the included studies was assessed by use of the modified Coleman Methodology Score. Results: After reviewing 371 studies, we identified 6 studies (5 retrospective case series and 1 prospective case series, all Level IV) that met the inclusion criteria, with a mean Coleman Methodology Score of 71.8 7.52 (range, 63 to 82). In these studies 178 patients (179 ankles) underwent arthroscopic suture anchor repair of the anterior talofibular ligament with a mean follow-up period of 38.9 months (range, 6 to 117.6 months). All patients were reported to have subjective improvement of their ankle instability, with complications in 31 cases. Conclusions: Studies of arthroscopic suture anchor technique to treat CAI are sparse, with moderate mean methodologic quality. The included studies suggest that the arthroscopic technique is a feasible procedure to restore ankle stability; however, on the basis of our review, this technique seems to be associated with a relatively high complication rate. Extensive cadaveric studies, clinical trials, and comparative studies comparing arthroscopic and open repair should be performed in the future. Level of Evidence: Level IV, systematic review of Level IV studies.
L
ateral ankle sprain is one of the most frequently encountered sports injuries.1,2 The basic mechanism of injury in lateral ankle sprains is excessive plantar flexion and inversion of the ankle, and the most commonly injured ligament is the anterior talofibular ligament (ATFL), followed by the calcaneofibular ligament (CFL). Most patients with acute ankle sprains can be successfully managed with conservative treatment, such
From the Department of Sports Medicine and Arthroscopy Surgery, Sports Medicine Center of Fudan University, Huashan Hospital, Shanghai, China. The authors report the following potential conflict of interest or source of funding: J.W., Y.H., S.C., H.L., J.Z., and Y.L. receive support from Sports Medicine Center of Fudan University. This work was supported by the National Natural Science Foundation of China (NSFC81101391). Received December 9, 2013; accepted February 14, 2014. Address correspondence to Yinghui Hua, Ph.D., Department of Sports Medicine and Arthroscopy Surgery, Sports Medicine Center of Fudan University, Huashan Hospital, Fudan University, No. 12 Urumq Middle Road, Shanghai, China 20040. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/13861/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.02.023
as bracing and physical therapy.3 However, chronic instability is reported to occur in 20% to 40% of sprains, with a reinjury rate as high as 80%.4-7 If residual instability persists after a solid course of nonoperative treatment, the patient should be offered surgical options to restore ankle stability.3,8 Many surgical techniques have been described for the treatment of chronic lateral ankle instability. These can be divided into anatomic repair, nonanatomic reconstruction, and anatomic reconstruction. Many reports have noted that the anatomic repair technique is generally preferred over reconstructive procedures.9-13 Numerous studies have shown good to excellent results with anatomic repair, with more than 85% of patients achieving good outcomes.12,14-16 Broström17 originally described anatomic repair of the lateral ligaments of the ankle as either direct repair after an intrasubstance injury or repair of the ligaments to their anatomic origins on the fibula with bone tunnels for avulsion injuries. Gould et al.18 later modified this technique by augmenting the repair with the inferior extensor retinaculum. This modified procedure has become the gold standard for anatomic repair techniques.19,20
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol
-,
No
-
(Month), 2014: pp 1-8
1
2
J. WANG ET AL.
considered. Not only studies in print journals but also electronically published articles and conference records were deemed as eligible for analysis and investigation. All references within the included articles were manually cross-referenced for potential inclusion to ensure that they were not missed in the initial search. Specific inclusion and exclusion criteria were applied to identify clinical studies that included preoperative conditions, postoperative outcomes, and complications. The articles were selected by the first 2 authors separately, and then, the selected articles were discussed together. If there was any disagreement, the subject was discussed until agreement was achieved. Figure 1 shows the process of searching, screening, identification, and inclusion. Inclusion Criteria The inclusion criteria for clinical articles were as follows: 1. English language 2. Clinical study using arthroscopic suture anchor technique 3. Preoperative conditions reported: both subjective and objective 4. Postoperative outcomes reported: both clinical and functional 5. Postoperative complications reported 6. Length of follow-up reported 7. Description of rehabilitation included 8. Level of Evidence from I to IV
Fig 1. Flowchart of search methods.
The arthroscopic technique is increasingly used to repair the lateral ligament complex of the ankle. On the basis of current studies of arthroscopic treatment of chronic ankle instability resulting from ATFL injury, we performed a literature review to investigate the outcomes of this technique and evaluate whether it can yield good outcomes in the treatment of chronic ankle instability with fewer complications.
Exclusion Criteria The exclusive criteria for clinical articles were as follows: 1. Non-English language 2. Failure to describe postoperative clinical or functional outcomes 3. Reports of surgical reconstructive procedures other than repair of ATFL 4. Articles describing arthroscopic thermal shrinkage technique to treat chronic lateral instability 5. Basic science studies, cadaveric studies, and anatomic and pathologic studies, as well as other reviews, letters to the editor, and expert opinions
Methods We performed a systematic review of the literature using multiple medical databases, including PubMed, Ovid, Elsevier ScienceDirect, Web of ScienceeConference Proceedings Citation Index, and the Cochrane Database of Systematic Reviews, for studies published between 1987 and September 2013. The search was performed separately and independently by the first 2 authors, using the following key words: arthroscopic, ankle instability, Broström, anterior talofibular ligament, and suture anchor. Articles with Level I, II, III, or IV Evidence were
Data Extraction and Analysis Data extraction and analysis were conducted by all authors separately and were then synthesized by the senior author. Relevant data included the following: authors; sample size; preoperative conditions (gender, age, time from injury to surgery, subjective feelings of instability, objective tests, and American Orthopaedic Foot & Ankle Society [AOFAS] score); postoperative outcomes including clinical (subjective improvement in ankle stability, objective tests, AOFAS score, and
3
SYSTEMATIC REVIEW OF SUTURE ANCHOR REPAIR Table 1. Summary of Outcomes in Studies Author James and Ryan2 Jordi et al.3 Kim et al.6 Corte-Real and Moreira22 Acevedo and Mangone23 Caio et al.24
Year 2013 2013 2011 2009
No. of Patients (No. of Ankles) 40 16 28 31
2011
23 (24)
2011
40
Age (yr) 45.6 (15-83) 29.3 (17-46) 38.6 (22-55) 33.3 (15-54) 39 (15-55) 28.8 (15-53)
Male/ Female 13/27 10/6 6/22 19/9
Follow-Up (mo) 12.13 4.27 (6-21) 22.3 (12-35) 15.9 (13-25) 27.5 (6-48)
Time From Injury to Surgery (mo) NR NR 16.8 (7-36) 7 (2-30)
Preoperative AOFAS Score 41.2 (23-64) 67 (59-77) 60.78 16.38 NR
Postoperative AOFAS Score 95.4 (84-100) 97 (95-100) 92.48 6.14 85.3 (65-100)
14/9
10.9
NR
NR
NR
24/14
117.6 (9.8 yr)
9 (6-19)
NR
90 (44-100)
NR, not reported.
radiographic findings) and functional outcomes; and postoperative complications. All data on complications were collected, and other intra-articular findings and types of management were also analyzed. Given the design heterogeneity of the included studies, a meta-analysis was considered inappropriate; thus no statistical comparison was made. Instead, comprehensive and specific descriptions of the studies and their conclusions were provided. The analysis was performed with Excel 2011 (Microsoft, Redmond, WA) and Stata processing software (version 12.0; StataCorp, College Station, TX). Quality Assessment All authors assessed the methodologic quality of each included study separately, according to the modified Coleman Methodology Score (CMS). The CMS is a 10criteria validated scoring system assessing the methodologic quality of scientific studies, with a final score ranging from 0 to 100. A perfect score of 100 represents a study design that largely avoids the influence of chance, various biases, and confounding factors.21 If a difference of more than 3 points existed among the authors’ results, we re-evaluated and discussed the findings until agreement was achieved.
Results Literature Review Our initial search returned 371 studies. After application of the inclusion criteria, 35 clinical studies remained. Of these 35 studies, 29 were excluded because they used reconstructive procedures or thermal shrinkage techniques; they were basic science, cadaveric, anatomic, or pathologic studies; or they failed to describe postoperative clinical or functional outcomes. Six clinical studies ultimately met our inclusion criteria.2,3,6,22-24 Data Extraction The Level of Evidence of the 6 included studies was Level IV, including 5 retrospective case series and 1 prospective case series. The included clinical studies described 178 patients (179 ankles) who underwent arthroscopic repair of the ATFL with the suture anchor
technique. All studies clearly stated the length of followup, with a mean of 38.9 months (range, 6 to 117.6 months). Postoperative AOFAS scores were reported in 5 studies, 3 of which included preoperative AOFAS scores. The range of postoperative AOFAS scores was 44 to 100. James and Ryan2 also used other evaluation measures to estimate postoperative outcomes, including preoperative visual analog scale (VAS) scores (mean, 8.2; range, 4 to 10), postoperative VAS scores (mean, 1.1; range, 0 to 5), and postoperative Karlsson-Peterson scores (mean, 93.6; range, 82 to 100). Three articles reported the time from injury to surgery, with a mean interval of 10.9 months (range, 6 to 36 months).6,22,24 One study noted that the mean time to return to full activity was 20.2 weeks (range, 12 to 42 weeks).2 In the study by Corte-Real and Moreira,22 the mean patient satisfaction score was 3.8 (range, 1 to 5). All patients in the included studies showed subjective improvement of their ankle instability. Five studies reported improvement in the AOFAS scores.2,3,6,22,24 No patients required reoperation. More details from the included articles are provided in Table 1. Complications Complications were reported in 31 cases among the 179 ankles undergoing arthroscopic repair of the ATFL with the suture anchor technique. The complication rate for each study is shown in Table 2. The types of complications included portal-site irritation in 4 patients; delayed wound healing in 4; nerve complications in 5, comprising neuritis of the intermediate dorsal cutaneous nerve in 1, superficial peroneal nerve numbness in 3 (1 persistent), and sural nerve neuritis in 1; additional acute ankle sprain in 4; superficial infection in 2; deep venous thrombosis in 2; and peroneal tendonitis in 1. Prominent asymptomatic suture knots under the skin were reported by Kim et al.6 in 3 cases and Corte-Real and Moreira22 in 4 cases. Acevedo and Mangone23 described 1 patient in whom neurologic problems developed 12 months postoperatively but were considered unrelated to the treatment. Kim et al.6 reported 2 additional cases of acute ankle sprain after surgery, and 1 patient had a distal fibular fracture during the postoperative period in the study of
4
J. WANG ET AL.
Table 2. Types of Complications in Each Study No. of Patients (No. of Ankles) 40
Author James and Ryan2
Jordi et al.3
16
Kim et al.6
28
Corte-Real and Moreira22
31
Acevedo and Mangone23
23 (24)
Caio et al.24
40
Complication Type (No.) Deep venous thrombosis (1) Neuritis of intermediate dorsal cutaneous nerve (1) Distal fibular fracture (1) Delayed wound healing (1) Superficial infection (1) Portal-site irritation (4) Superficial infection (1) Prominent asymptomatic suture knots (3) Additional acute ankle sprain (2) Delayed wound healing (3) Superficial peroneal nerve numbness (3 [1 persistent]) Additional acute ankle sprain (2) Deep venous thrombosis (1) Prominent asymptomatic suture knots (4) Peroneal tendonitis (1) Sural nerve neuritis (1) Neurologic problems 12 mo postoperatively (1) 0
James and Ryan.2 The authors noted that these 3 cases were unrelated to surgery; however, they seemed to be associated with severe morbidity postoperatively, especially with such short times to follow-up, so we defined them as major complications. More details on the complications in each study are shown in Table 2. Intra-articular Findings We also reviewed information on intra-articular lesion status. All the studies described the concomitant intra-articular pathologic features and their treatment. The majority of findings comprised synovitis, loose bodies, osteochondral lesions, anterior spurs, and anterior soft-tissue impingement. We consider the occurrence of intra-articular lesions to be high. All of these findings were managed during the procedure. Methodologic Quality Assessment The mean modified CMS was 71.8 7.52 (range, 63 to 82) for all included articles. The overall CMS for each criterion and the mean CMS in each study are shown in Tables 3 and 4, respectively.
Discussion Anatomic repair of the lateral ligament complex of the ankle based on the Broström procedure is usually the first choice of treatment for chronic ankle instability.4,17,25 The arthroscopic technique has increasingly been used in recent years because of its obvious advantages as a minimally invasive method. Arthroscopic repair was first described by Hawkins,26 who placed a staple on the talus to plicate the talofibular ligament. He reported a series of 25 patients with good results; however, the prominent staples had caused patients some discomfort. Surgeons have modified the technique
Total No. of Complications 3
Complication Rate 7.5%
2
12.5%
10
35.7%
13
41.9%
3
12.5%
0
0%
progressively. After the enthusiasm generated by the treatment of shoulder instability with thermal capsular shrinkage, a similar method was used in the ankle to tighten lax lateral ligaments.22 Some studies reported good subjective outcome results.27-30 However, the lack of significant improvement in mechanical stability is the most obvious shortcoming of this technique. A suture anchor technique was later developed to address problems such as discomfort caused by prominent staples or mechanical instability with the shrinkage technique, and relatively high success rates have been obtained. The method has been increasingly applied to restore ankle stability by attaching the ATFL to the fibula and/or talus to reconstruct the lateral ligament complex of the ankle. A cadaveric study performed by Giza et al.20 showed that arthroscopic anatomic repair of the lateral ligaments of the ankle could achieve comparable biomechanical results to open procedures. In all of the studies we reviewed, the suture anchor was placed in the fibula to repair the ATFL. Some also attached the inferior extensor retinaculum to the periosteum of the fibula to Table 3. Overall CMS Score for Each Criterion Criteria (Maximum Score) Part A Study size (10) Mean follow-up, mo (5) No. of procedures (10) Type of study (15) Diagnostic certainty (5) Surgery description (5) Rehabilitation description (10) Part B Outcome criteria (10) Procedure for outcomes (15) Selection process (15) Total score (100)
Mean
SD
Range
3.33 2.67 10 1.67 5 5 10
1.63 1.97 0 4.08 0 0 0
0-4 0-5 10 0-10 5 5 10
10 11.7 12.5 71.8
0 1.63 2.74 7.52
10 11 10-15 63-82
Study Size 4 0 4 4 4 4 Publication Year 2013 2013 2011 2009 2011 2011 Author James and Ryan2 Jordi et al.3 Kim et al.6 Corte-Real and Moreira22 Acevedo and Mangone23 Caio et al.24
Table 4. Detailed CMS Scores for Each Study
Mean Follow-Up (mo) 2 2 2 5 0 5
No. of Procedures 10 10 10 10 10 10
Type of Study 10 0 0 0 0 0
Diagnostic Certainty 5 5 5 5 5 5
Surgery Description 5 5 5 5 5 5
Rehabilitation Description 10 10 10 10 10 10
Outcome Criteria 10 10 10 10 10 10
Procedure for Outcome 11 11 11 11 11 15
Selection Process 15 10 15 10 10 15
Total Score 82 63 72 70 65 79
SYSTEMATIC REVIEW OF SUTURE ANCHOR REPAIR
5
reinforce the repair.18,24 CFL repair was not performed. James and Ryan2 indicated that direct ATFL repair without CFL repair can result in good to excellent postoperative outcomes. Jordi et al.3 described a “knotless suture anchor” technique to avoid the discomfort or pain caused by a prominent suture knot. Although arthroscopic suture anchor repair of the ATFL to treat chronic ankle instability is evolving rapidly, a high rate of complications (5.3% to 29%) has been described in many case series according to Jordi et al.3 With the exception of Caio et al.,24 who reported that no patient had wound dehiscence and/or infection, paresthesia, or numbness and there was no marked limitation in eversion and inversion after the operation at 9.8 years’ follow-up, all the other studies in our review showed relatively high complication rates (from 7.5% to 41.9%). Neuritis of the superficial peroneal or sural nerve and pain or discomfort resulting from a prominent anchor or suture knot are frequently reported complications.3,6,22,23 To mitigate the risk of nerve damage caused by the arthroscopic technique, especially to avoid neuritis of the superficial peroneal and sural nerves, surgeons must have good arthroscopic skills and a thorough knowledge of foot and ankle anatomy. Jordi et al.3 in their study also recommended caution on the part of the surgeon when creating portals, introducing instruments, and using instruments to reduce the risk of nerve injuries. Postoperative ligament stability is evaluated by clinical examination. With open surgery and delayed primary ligament repair, subjective residual instability has been reported in 5% to 12% of patients.31-35 There were some positive findings in the studies we reviewed: Caio et al.24 reported that the postoperative anterior drawer test showed grade 0 laxity in 25 patients and grade 1 laxity in 13 patients; in the study performed by Kim et al.,6 3 patients showed laxity on postoperative stress radiographs, with more than 3 mm of displacement compared with the contralateral side. Most of the patients reported obvious subjective improvement in their ankle stability and were able to return to their preinjury activity level, indicating that mechanical instability and functional instability are not necessarily closely related. We also collected data on instability recurrence. Kim et al.6 and Corte-Real and Moreira22 both reported 2 cases of additional acute ankle sprain; the follow-up stress radiographs in these patients did not show any mechanical instability, and all were treated conservatively and returned to their postoperative status. Some studies describing acute and delayed open ligament repair have reported the incidence of postoperative stiffness.33,36-38 A study by Hennrikus et al.32 found that 9% of patients who underwent the open Broström procedure thought the repair was too tight, as compared with 28% of patients who underwent the tenodesis procedure. In the studies
6
J. WANG ET AL.
we reviewed, no cases of stiffness were reported. Future research is required to critically evaluate whether the arthroscopic technique effectively prevents stiffness and morbidity. Whether to manage intra-articular lesions during surgery is controversial. Ankle instability is frequently accompanied by intra-articular lesions,6,7,39 including osteochondral lesions, synovitis, loose bodies, anterior spurs, and anterior soft-tissue impingement. During the arthroscopic procedure, concomitant intra-articular injuries can be evaluated and treated before ligament repair. A study by Ferkel and Chams7 suggested that chondral lesions did not influence the outcome of the procedure. However, no comparison was performed between patients with and without chondral lesions, so their conclusion needs further consideration. Many reports have indicated that concomitant intra-articular injuries might be associated with postoperative rehabilitation results and patients’ subjective feelings. Intraarticular osteochondral lesions of the talus have been considered the strongest predictors of poor clinical outcomes. In several studies researchers found a significant association between chondral injury and postoperative ankle pain. Patients with osteochondral lesions were more likely to express dissatisfaction than patients without these lesions.24,25,40,41 For this reason, arthroscopic investigation and management of the joint are performed before many authors perform the procedure. Hua et al.25 suggested that performing ankle arthroscopy to treat intra-articular injuries is a safe procedure for the treatment of patients with chronic ankle instability and produced satisfactory surgical outcomes. In this review, all the authors treated intraarticular lesions before ligament repair and no patient reported subjective dissatisfaction after surgery. Certain benefits can be obtained from arthroscopic treatment; for example, it allows direct visualization of intra-articular structures without an extensive surgical approach, and it allows for stress testing and evaluation of the competency of the ligamentous structures surrounding the ankle in cases of joint laxity.42 Because of smaller incisions, patients may quickly return to normal activity levels. In addition, the arthroscopic approach can be easily converted to open surgery if necessary. On the other hand, the arthroscopic procedure has some disadvantages, such as the risk of complications, high surgical equipment and technique needs, and a steep learning curve. Limitations The level of evidence of this study is relatively low, and the methodologic quality is moderate. Given the design heterogeneity of the included studies, we were unable to perform a meta-analysis; thus no statistical comparison was made. The sample size of all included studies was small, the study population was
heterogeneous, and all but 1 study included a single cohort. There were no direct comparisons between the described approach and other techniques (e.g., an open procedure). The studies were not randomized or comparative case series, which can result in biases, including selection bias and performance bias. The postoperative outcomes were divided into 2 main componentsdthe subjective evaluation of the patient and the objective findings of the authorsdwhich could allow physician bias to influence the results. In addition, not every study noted patient satisfaction during follow-up, and there was a large variation in follow-up time among studies (range, 6 to 117.6 months). These variations could result in less valid measurements of general long-term postoperative outcomes. Some of the included studies provided insufficient information. Instability was not quantified preoperatively and postoperatively in all studies. Lateral ligament disruption of the ankle is generally diagnosed by stress radiography. However, this method provides only a mechanical assessment of ankle stability under a limited stress force, which may be less than the actual tensile force on the ligaments during sports or other strenuous activities.3 Most of the studies used AOFAS scores to estimate the patients’ preoperative condition and postoperative outcome. Although other evaluation standards exist, such as VAS and Karlsson-Peterson scores, not all the studies used these tools to estimate the postoperative outcomes. This review contains no protocol for arthroscopic suture anchor repair of the lateral ligament ankle complex to treat CAI, which may lead to reporting bias. Extensive cadaveric and clinical studies, as well as comparisons with other procedures, should be performed to compensate for the weaknesses of existing studies.
Conclusions After a full-scale investigation and evaluation of existing studies, considering the patients’ subjective feelings, postoperative outcomes, and physical examination findings, we deem that even though arthroscopic repair of the lateral ligament complex with the suture anchor technique can restore ankle stability, the risk of complications is among the main considerations based on current evidence. Extensive cadaveric studies, clinical trials, and comparative studies comparing arthroscopic and open repair should be performed in the future to further evaluate the efficacy of arthroscopic treatment.
References 1. Colville M. Surgical treatment of the unstable ankle. J Am Acad Orthop Surg 1998;6:368-377. 2. James C, Ryan R. The “all inside” arthroscopic Broström procedure: A prospective study of 40 consecutive patients. J Foot Ankle Surg 2013;52:568-574.
SYSTEMATIC REVIEW OF SUTURE ANCHOR REPAIR 3. Jordi V, Pau G, Alexandro P, Eduard R, Fernando P. Allinside arthroscopic lateral collateral repair for ankle instability with a knotless suture anchor technique. Ankle Foot Int 2013;34:1701-1709. 4. Baumhauer JF, O’Brien T. Surgical considerations in the treatment of ankle instability. J Athl Train 2002;37:458-462. 5. Boardman DL, Liu SH. Contribution of the anterolateral joint capsule to the mechanical stability of the ankle. Clin Orthop Relat Res 1997;(341):224-232. 6. Kim ES, Lee TK, Park JS, Lee YK. Arthroscopic anterior talofibular ligament repair for chronic ankle instability with a suture anchor technique. Orthopedics 2011;34:273. 7. Ferkel RD, Chams RN. Chronic lateral instability: Arthroscopic findings and long-term results. Foot Ankle Int 2007;28:24-31. 8. Karlsson J, Lansinger O. Lateral instability of the ankle joint. Clin Orthop Relat Res 1992;(276):253-261. 9. Bahr R, Pena R, Shine J, Lew WD, Tyrdal S, Engebretsen L. Biomechanics of ankle ligament reconstruction: An in vitro comparison of the Broström repair, Watson-Jones reconstruction, and a new anatomic reconstruction technique. Am J Sports Med 1997;25:424-432. 10. Fujii T, Kitaoka HB, Watanabe K, Luo ZP, An KN. Comparison of modified Broström and Evans procedures in simulated lateral ankle injury. Med Sci Sports Exerc 2006;38:1025-1031. 11. Hollis JM, Blasier RD, Flahiff CM, Hofmann OE. Biomechanical comparison of constructive techniques in simulated lateral ankle ligament injury. Am J Sports Med 1955;23:678-682. 12. Krips R, van Dijk CN, Halasi PT, et al. Long-term outcome of anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: A multicenter study. Foot Ankle Int 2001;22:415-421. 13. Liu SH, Baker CL. Comparison of lateral ankle ligamentous reconstruction procedures. Am J Sports Med 1994;22: 313-317. 14. Hamilton WG, Thompson FM, Snow SW. The modified Broström procedure for lateral ankle instability. Foot Ankle 1993;14:1-7. 15. Bell SJ, Mologne TS, Sitler DF, Cox JS. Twenty-six-year results after Broström procedure for chronic lateral ankle instability. Am J Sports Med 2006;34:975-978. 16. Thermann H, Zwipp H, Tscerne H. Treatment algorithm of chronic ankle and subtalar instability. Foot Ankle Int 1997;18:163-169. 17. Broström L. Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures. Acta Chir Scand 1966;132: 551-565. 18. Gould N, Seligson D, Gassman J. Early and late repair of lateral ligament of the ankle. Foot Ankle 1980;1:84-89. 19. Brodsky AR, O’Malley MJ, Bohne WH, Deland JA, Kennedy JG. An analysis of outcome measures following the Broström-Gould procedure for chronic lateral ankle instability. Foot Ankle Int 2005;26:816-819. 20. Giza E, Shin EC, Wong SE, et al. Arthroscopic suture anchor repair of the lateral ligament ankle complex: A cadaveric study. Am J Sports Med 2013;41:2567-2572. 21. Coleman BD, Khan KM, Maffulli N, Cook JL, Walk JD. Studies of surgical outcome after patellar tendinopathy: Clinical significance of methodologic deficiencies and
22. 23. 24.
25.
26. 27.
28.
29.
30.
31. 32.
33.
34.
35. 36.
37.
38.
39.
7
guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports 2000;10:2-11. Corte-Real N, Moreira R. Arthroscopic repair of chronic lateral ankle instability. Foot Ankle Int 2009;30:213-217. Acevedo J, Mangone P. Arthroscopic lateral ankle ligament reconstruction. Tech Foot Ankle Surg 2011;10:111-116. Caio N, Fernando R, Angelo B, Inacio A, Moises C, Nicola M. Arthroscopic-assisted Broström-Gould for chronic ankle instability: A long-term follow-up. Am J Sports Med 2011;39:2381-2388. Hua YH, Chen SY, Li YX, Chen JW, Li H. Combination of modified Broström procedure with ankle arthroscopy for chronic ankle instability accompanied by intra-articular symptoms. Arthroscopy 2010;26:524-528. Hawkins RB. Arthroscopic stapling repair for chronic lateral instability. Clin Podiatr Med Surg 1987;4:875-883. Maiotti M, Massoni C, Tarantino U. The use of arthroscopic thermal shrinkage to treat chronic lateral ankle instability in young athletes. Arthroscopy 2005;21:751-757. Oloff LM, Bocko AP, Fanton G. Arthroscopic monopolar radiofrequency thermal stabilization for chronic lateral ankle instability: A preliminary report on 10 cases. J Foot Ankle Surg 2000;39:144-153. Berlet GC, Saar WE, Ryan A, Lee TH. Thermal-assisted capsular modification for functional ankle instability. Foot Ankle Clin 2002;7:567-576. de Vries JS, Krips R, Blankevoort L, Fievez AW, van Dijk CN. Arthroscopic capsular shrinkage for chronic ankle instability with thermal radiofrequency: Prospective multicenter trial. Orthopedics 2008;31:655. Sammarco VJ. Complications of lateral ankle ligament reconstruction. Clin Orthop Relat Res 2001;(391):123-132. Hennrikus WL, Mapes RC, Lyons PM, Lapoint JM. Outcomes of the Chrisman-Snook and modified-Broström procedures for chronic lateral ankle instability: A prospective, randomized comparison. Am J Sports Med 1996;24:400-404. Karlsson J, Bergsten T, Lansinger O, Peterson L. Surgical treatment of chronic lateral instability of the ankle joint: A new procedure. Am J Sports Med 1989;17:268-274. Karlsson J, Eriksson BI, Bergsten T, Rudholm O, Swärd L. Comparison of two anatomic reconstructions for chronic lateral instability of the ankle joint. Am J Sports Med 1997;25:48-53. Liu SH, Jacobson KE. A new operation for chronic lateral ankle instability. J Bone Joint Surg Br 1995;77:55-59. Cass JR, Morrey BF, Katoh Y, Chao EY. Ankle instability: Comparison of primary repair and delayed reconstruction after long-term follow-up study. Clin Orthop Relat Res 1985;(198):110-117. Kitaoka HB, Lee MD, Morrey BF, Cass JR. Acute repair and delayed reconstruction for lateral ankle instability: Twenty-year follow-up study. J Orthop Trauma 1997;11: 530-535. Rudert M, Wulker N, Wirth CJ. Reconstruction of the lateral ligaments of the ankle using a regional periosteal flap. J Bone Joint Surg Br 1997;79:446-451. Okuda R, Kinoshita M, Morikawa J, Yasuda T, Abe M. Arthroscopic findings in chronic lateral ankle instability: Do focal chondral lesions influence the results of ligament reconstruction? Am J Sports Med 2005;33:35-42.
8
J. WANG ET AL.
40. Choi WJ, Lee JW, Han SH, Kim BS, Lee SK. Chronic lateral ankle instability: The effect of intra-articular lesions on clinical outcome. Am J Sports Med 2008;36:2167-2172. 41. Takahashi T, Nakahira M, Kaho K, Kawakami T. Anatomical reconstruction of chronic lateral ligament
injury of the ankle using pedicle tendon of the extensor digitorum longus. Arch Orthop Trauma Surg 2003;123: 175-179. 42. Ferkel RD, Small HN, Gittins JE. Complications in foot and ankle arthroscopy. Clin Orthop Relat Res 2001;391:89-104.
