Is Internal brace augmentation a gold standard treatment compared to isolated Modified Brostrom Gould repair for chronic lateral ligament ankle instability? Effect on functional outcome and Return to preinjury activity: A retrospective analysis

Comparison of the efficacy of the modified internal brace and the arthroscopic Broström-Gould procedure for chronic lateral ankle instability

PURPOSE

To compare the efficacy of an internal brace and the arthroscopic Broström-Gould procedure for chronic lateral ankle instability (CLAI).

METHODS

The clinical data of 71 patients who were diagnosed with chronic lateral ankle instability between May 2020 and May 2022 were retrospectively analyzed. The American Orthopedic Foot and Ankle Society (AOFAS) scale, Foot and Ankle Ability Measure (FAAM), and Visual Analogue Scale (VAS) were used to assess clinical outcomes.

RESULTS

A total of 59 patients were followed up for a mean of 21 months (range, 16-24 months). Thirty-seven patients underwent the modified Broström-Gould (IB) procedure, and twenty-two patients underwent the arthroscopic Broström-Gould (ABG) procedure. The mean postoperative VAS score (P = 0.790), AOFAS score (P = 0.252), FAAM daily activity score (P = 0.983), and FAAM for sports activity score (P = 0.379) were not significantly different between the ABG and IB groups at the final follow-up. However, the FAAM sports score was better in the internal brace group than in the arthroscopy group at the 1-year postoperative follow-up (P = 0.025).

CONCLUSION

Patients treated with an internal brace recovered faster than those who underwent the arthroscopic ABG procedure. However, no other significant differences were observed between the two methods.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

High incidence of post-operative re-sprain following suture tape implantation for anterior talofibular ligament insufficiency and risk factors for post-operative re-sprain

PURPOSE

Anterior talofibular ligament (ATFL) insufficiency encompasses situations in which (i) frequent sprains cause ATFL loss, as evidenced by ATFL non-visualization on preoperative magnetic resonance imaging; or (ii) minimal healthy ATFL tissue for repair is left after the removal of the large os subfibulare. Suture tape implantation can be indicated for these cases rather than conventional ligament repair. This study was designed to investigate the incidence of post-operative re-sprain in patients who underwent suture tape implantation for ATFL insufficiency, and risk factors influencing the occurrence of post-operative re-sprain were identified.

METHODS

A total of 68 patients who underwent suture tape implantation for ATFL insufficiency from January 2016 to December 2021 were retrospectively evaluated. The minimum follow-up duration for inclusion was 2 years after surgery. All included patients were divided into two groups according to the presence of post-operative re-sprain during the follow-up period. Multiple clinico-radiographic parameters were measured, and binary logistic regression analysis was performed to determine the factors influencing post-operative re-sprain.

RESULTS

Post-operative re-sprain occurred in 19 of the 68 patients (27.9%), and multiple re-sprains persisted in 7 patients (10.3%). Post-operative re-sprain was more likely to occur in patients who smoked after surgery (odds ratio [OR], 3.510), had generalized ligament laxity (OR, 4.364) and engaged in occupations requiring high physical activity levels (OR, 4.421), including soldiers, professional athletes, student-athletes and mailmen.

CONCLUSION

The incidence of multiple post-operative re-sprains was high after suture tape implantation for ATFL insufficiency. Caution is particularly warranted in patients with risk factors, necessitating meticulous attention to their care. Careful consideration of strategies to mitigate risks when performing the surgery is also recommended.

LEVEL OF EVIDENCE

Level III.

Early Mobility and Rehabilitation Protocol after Internal Brace Ankle Stabilization

Chronic lateral ankle instability is a common diagnosis in foot and ankle clinics. Internal Brace (IB) augmentation is a surgical procedure that utilizes fibertape augmentation of the lateral ankle ligaments. Studies have shown the superiority of fibertape augmentation over traditional lateral ankle stabilization procedures such as the Brostrom or Brostrom-Gould. The IB procedure has been described elsewhere and the fixation involves placing bone anchors with attached suture tape at each end of the Brostrom repair augmenting the fixation. Various studies exist that support the mechanical advantage of the Brostrom with IB over non augmented repair. This technique allows for earlier weight bearing and range of motion which translates into earlier return to activity and sport. While there are guidelines for rehabilitation after Brostrom procedures, there are currently no guidelines regarding rehabilitation after the IB. The purpose of this clinical commentary is to describe an early mobility and rehabilitation protocol after IB augmentation for the ankle. The post operative protocol provides treatment goals, weight bearing status recommendations, and rehabilitation intervention suggestions after IB augmentation.

Level of Clinical Evidence

V.

Clinical and biomechanical outcomes following patellar tendon repair with suture tape augmentation

PURPOSE

Patellar tendon ruptures (PTR) occur predominantly in middle-aged patients following indirect trauma. The aim of this study was to quantify the short-term results using a suture tape augmentation technique for the repair of PTR.

METHODS

All consecutive patients with acute (< 6 weeks) PTR who underwent suture tape augmentation between 03/2014 and 11/2019 at a single institution with a minimum follow-up of 12 months were retrospectively evaluated. Outcome measures included Visual Analog Scale (VAS) for pain, Tegner Activity Scale (TAS) and return to sport rates, Lysholm score, International Knee Documentation Committee subjective knee form (IKDC) as well as Knee Injury and Osteoarthritis Outcome Score (KOOS). Additionally, a standardized clinical examination and an isometric strength evaluation of knee extension and flexion were performed. It was hypothesized that high return to sport rates and good functional outcome would be observed and that the majority of patients would not present with a severe (> 20%) knee extension strength deficit when compared to the contralateral side.

RESULTS

A total of 7 patients (mean age 37.0 ± SD 13.5 years; 6 male/1 female) were available for final assessment at a median follow-up of 17.0 (25-75% IQR 16.0-77.0) months. Three injuries occurred during ball sports, two injuries occurred during winter sports, and one injury each occurred during a motorcycling and skateboarding accident. The average time between trauma and surgery was 4.7 ± 2.6 days. At follow-up, patients reported little pain (VAS: 0 [0-0.4]). Return to sport was possible for all patients 8.9 ± 4.0 months postoperatively at a high level (TAS: 7.0 [6.0-7.0]). Five patients (71.4%) returned to the preinjury level of play, and 2 (28.6%) did not return to the preinjury level of play. Patient-reported outcome measures were moderate to good (Lysholm score: 80.4 ± 14.5; IKDC: 84.2 ± 10.6; KOOS subscales: pain 95.6 ± 6.0, symptoms 81.1 [64.9-89.1], activities of daily living 98.5 [94.1-100], sport and recreation function 82.9 ± 14.1 and knee-related quality of life 75.9 ± 16.3). All patients were very satisfied (57.1%) or satisfied (42.9%) with the postoperative result. No postoperative complications were reported. Strength measurements revealed a severe knee extension deficit in 3 patients (42.9%), but no significant deficit of isometric knee extension or flexion strength in comparison with the contralateral side was observed overall (p > 0.05).

CONCLUSION

Suture tape augmentation in acute PTR repair leads to good functional outcome without major complications. Although a severe knee extension strength deficit may occur in some patients postoperatively, an excellent return to sports rate and high patient satisfaction can be expected nonetheless.

LEVEL OF EVIDENCE

Retrospective cohort study; III.

Anterior Talo-Fibular Ligament Reconstruction With InternalBrace™ for Chronic Lateral Ankle Instability in Pediatric Patients

INTRODUCTION

Ankle injuries and instability in a pediatric age group are common problems and often underreported. The injuries can range from a relatively benign ankle sprain to pain-limiting ankle instability that can inhibit the child from participating in sporting activities. However, conservative management and physiotherapy are the mainstay of treatment; a small group of patients present with persistent instability and benefit from surgical intervention in lateral ligament reconstruction. Our study looked at pediatric patients who had instability following failed conservative management.

METHODS

Retrospective analysis of 14 patients with Chronic lateral Ankle instability (CLAI) who underwent Modified Brostrom-Gould repair( MBG) with or without Internal brace augmentation between January 2015 and October 2020. Patients were evaluated for the visual analogue scale (VAS), Manchester-oxford foot questionnaire (MOxFQ), subjective satisfaction, and return to preinjury activity level.

RESULTS

Pain score improved from 8 (average 5-9) to 1 (average 0-3) following surgery. Functional assessment was made by assessing the Manchester Oxford questionnaire pre-and postoperatively. MOxFQ scores improved from 64 (8 SD) to 7 (15 SD). Thirteen of fourteen patients returned to normal sporting activities at the final follow-up.

CONCLUSION

Modified Brostrom-Gould with InternalBrace™ augmentation is an excellent procedure for chronic lateral ligament injuries in the Paediatric population. It can be safely performed if we respect the anatomy and the physeal growth plate. It allows faster rehabilitation and return to preinjury activity level.

Brace for Impact: A Retrospective Analysis of the Modified Broström-Gould Procedure With and Without Internal Brace Augmentation

Background Chronic lateral ankle instability (CLAI) is caused by lateral ankle ligament weakness or rupture secondary to recurrent sprains. The surgical management has traditionally involved a modified Broström-Gould (MBG) procedure with or without internal brace (IB) augmentation. This study aims to demonstrate the improved outcomes for patients undergoing an MBG procedure with IB augmentation for CLAI. Methodology A retrospective analysis was performed among 40 patients undergoing an MBG procedure with or without IB for CLAI at a large teaching hospital between January 2012 and June 2019. Functional outcomes were measured using the Manchester-Oxford Foot Questionnaire (MOxFQ). Clinic letters were reviewed to assess additional outcomes including postoperative complications, revision surgery rate, time in a plaster cast, and time to full weight-bearing. Results A total of 23 patients were included in the study, with seven undergoing both MBG and IB procedures and 16 undergoing MBG intervention alone. The average age was 37.1 years in the IB group and 35.7 years in the MBG group. The mean MOxFQ overall raw scores (10.9 vs. 33.6, p < 0.016), standing and walking MOxFQ subscale (4 vs. 15.2, p < 0.012), pain MOxFQ subscale (4.86 vs. 10.9, p < 0.042), and social interaction subscale (2 vs. 7.5 p < 0.023) all showed significantly better results for the IB group versus the MBG group. Patients in the IB group had significantly less number of weeks in plaster than the MBG group and were able to fully weight bear sooner (4.14 vs. 6, p < 0.01). The MBG group suffered a postoperative complication in seven patients compared to zero in the IB group (p < 0.057). There were three re-ruptures in the MBG group requiring further revision surgery compared to zero in the IB group (3 vs. 0, p < 0.53). Conclusions MBG surgery with IB augmentation for CLAI appears to have better outcomes in terms of overall function and may have fewer overall complications. The IB group displayed a lower recurrence of pain, less time in a plaster cast, and a quicker return to walking.

Lateral Ulnar Collateral Ligament Repair With Suture-Tape Augmentation for Traumatic Elbow Instability

PURPOSE

Ligament repair with suture-tape augmentation has been used in the operative treatment of joint instability and may have advantages with respect to early motion and stability. The purpose of this investigation was to describe the clinical results of traumatic elbow instability treated with lateral ulnar collateral ligament repair with suture-tape augmentation.

METHODS

All cases of acute and chronic elbow instability treated surgically between 2018 and 2020 were included if they underwent ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament as part of the procedure. Cases with <6 months of follow-up were excluded. A manual chart review was performed to record patient demographics as well as injury and surgery characteristics. Radiographic outcomes, range of motion, and patient-reported outcome measures, including the visual analog pain scale and Disabilities of the Arm, Shoulder, and Hand, were recorded. Range of motion measurements were recorded at the end of the clinical follow-up, as were surgical complications.

RESULTS

Eighteen cases were included with a mean follow-up of 20 months. Five (28%) cases involved a high-energy mechanism, and 11 (62%) cases involved terrible triad fracture dislocations. The mean Disabilities of the Arm, Shoulder, and Hand questionnaire and visual analog pain scale scores were 17 and 2, respectively. The mean flexion-extension arc was 124°, and 2 (11%) cases had <100° flexion-extension arc. There were 2 (11%) postoperative complications, and both cases had postoperative instability requiring reoperation. We observed no cases of capitellar erosion from the suture-tape material.

CONCLUSIONS

For complex elbow instability, ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament results in acceptable functional outcomes and a reoperation rate comparable with other joint stabilization procedures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.