What Is the Best Treatment for Recurrent Ankle Instability?

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Chapter 78 What Is the Best Treatment for Recurrent Ankle Instability?

ALASTAIR. YOUNGER, MB, ChB, FRCSC, Msc, ChM

Incidence of Recurrent Ankle Instability

Most acute injuries are treated by a rehabilitation program. The remaining 15% to 20% who remain symptomatic may require surgical intervention.¹ In the United Kingdom, 302,000 sprains are treated per year.² Recurrent sprains may result in more lost days of sport than the initial injury.³

Anatomy of the Lateral Collateral Ligaments

The lateral collateral ligaments stabilize the ankle joint to episodes of inversion sprains. The anterior talofibular ligament runs from the anterior aspect of the fibula to the neck of the talus laterally at its junction to the body of the talus.⁴ The calcaneofibular ligament starts just inferior and posterior to the origin of the talofibular ligament, and inserts into the lateral border of the calcaneus running posteriorly.⁵ The talofibular ligament therefore stabilizes the ankle by preventing the talus from subluxing anteriorly in the ankle mortise, whereas the calcaneofibular ligament prevents inversion of both the talus and calcaneus at the ankle joint and subtalar joint, respectively.

Pathoanatomy

Rupture of the lateral ligaments may cause instability in the ankle, in the subtalar joint, or both. During an acute episode of instability, the talus will rotate within the ankle mortise and can subject a shear load onto the cartilage on the dome of the talus. The medial dome may impinge on the medial side of the distal tibia causing a central to posteromedial chondral injury. Alternatively, the lateral dome may impinge on the fibula causing a posterolateral injury. Ongoing instability and the chondral injury can cause further cartilaginous degeneration, allowing the ankle joint to become inflamed with associated synovitis. If long-term instability is persistent, significant ankle degeneration occurs with osteophytes formation, both of which may cause symptomatic impingement. Inversion sprains may also overload the peroneal tendon complex, causing stretching or incompetency of SPR, peroneal subluxation/injury, and synovitis.

The anatomy of the hindfoot has a critical effect on the loading of the lateral ligament complex. A cavus foot position may cause medial displacement of the joint reaction force in the ankle, increasing strain on the lateral collateral ligaments.⁶ Posterior displacement of the tip of the fibula has been hypothesized as being the cause of recurrent instability. These anatomic variations may, however, represent part of a constellation of cavus foot deformity.⁷ Symptomatic chronic instability may be caused by the combination of foot shape and an acute injury. A study of patients with ankle instability awaiting surgery compared with normal control subjects showed that those with instability had a more varus heel.⁶

PREVENTION OF ANKLE INSTABILITY

Theoretically, bracing may prevent recurrent ankle instability. The application of a brace may assist in prevention of instability by mechanical support and by improved proprioception. Bracing has also been used to prevent ankle instability; this is supported through reviews in the Cochrane database but is beyond the scope of this chapter.

TREATMENT OF THE ACUTE INJURY

The general consensus of the literature is that the results of early surgical repair do not result in better outcomes than nonoperative treatment.⁸^–¹¹ Two Cochrane database reviews showed insufficient evidence to recommend surgical intervention. The most recent is based on the review of 20 articles. A trend existed toward worse outcome in the surgical group for longer recovery times, stiffness, and surgical complications {Kerkhoffs, 2007 #585} (grade B). Repair and reconstruction is therefore recommended only for patients with chronic symptoms of ankle instability.

Limitations of Outcomes Studies

In the Cochrane database review, no evidence was found to support acute lateral ligament reconstruction compared with conservative treatment. However, the studies analyzed were not designed well enough to definitively answer the question.⁹ The obvious limitations of articles on recurrent lateral ankle instability include retrospective design with nonvalidated outcome scores without control groups. Less obvious may be the presence or absence of copathologies with ankle instability. Hintermann and colleagues ¹² report on 148 patients with medial or lateral instability. Cartilage injury was found in 66% of patients with lateral instability, and 98% of patients with medial instability. Another study showed a 98% rate of intra-articular pathology is associated with lateral ankle instability. The author notes the most common finding was synovitis with a 25% rate of chondral injuries in the ankle.¹³ Other authors have documented similar findings.¹³^–¹⁵ Injury to the peroneal tendons and tendonitis are associated with recurrent lateral ankle instability^16,¹⁷ with 25% of patients having a peroneal tendon injury.

In summary, older studies do not address the copathologies, nor do they discuss or outline their concomitant treatment protocol on finding these associated issues. For this reason alone, the outcomes for ankle ligament stabilization may be improved in recent articles with the advent of routine magnetic resonance imaging (MRI) and ankle arthroscopy, and treatment of osteochondral defects. Based on the Level IV studies, a grade I recommendation exists for the routine use of advanced diagnostic testing, such as MRI. The diagnostic role of routine arthroscopic debridement at the time of lateral ligament reconstruction has not been determined; however, its use is now recommended by some authors ^15,¹⁸ (grade I). More studies are required in regard to this specific issue.

Nonoperative Treatment of Recurrent Ankle Instability

Nonoperative treatment of recurrent ankle instability may include casting, bracing, anti-inflammatory medication, taping, and physiotherapy. A review of the literature showed a number of studies related physiotherapy, cast, and brace treatment. Most of these modalities are used in combination. Physiotherapy seems to be better studied and the outcomes outlined better than brace treatment.

Brace Treatment.

Overall bracing may be more effective than no treatment with Level C evidence: poor-quality evidence (Level IV or V with consistent findings) for or against recommending intervention, with most studies being of Level IV quality. Although bracing may be effective, the literature is too inconsistent to recommend bracing over taping or to recommend one brace over another.

Strengths of these brace studies in general are that the majority are prospective and do contain a control group. One criticism is that they do not have clinical results as an end point, but instead use indirect measures such as dynamometer testing or peroneal reaction times. This weakness makes many of the articles, which otherwise have good study design, hard to place in the context of outcome research.

The obvious study, comparison of brace versus no brace treatment on the midterm outcome of ankle instability or symptoms reported by the patient, has not been done. The articles written on bracing for chronic instability are summarized in Table 78-1. Future research should ideally be prospective, randomized, and based on patient-reported outcomes.

TABLE 78-1 Brace Treatment for Ankle Instability

Physiotherapy.

Three studies of Level II quality exist supporting the use of physiotherapy for recurrent instability. Four studies are Level II and IV quality, and three cannot be rated because they report outcomes that were not clinical and focused on indirect evidence such as peroneal reaction times. Based on these studies, a grade B recommendation exists for treatment of ankle instability with physiotherapy. One study used an unusual treatment regimen ²⁸ that is an unconventional form of physiotherapy—a bidirectional bicycle pedal that is not available to most patients (Table 78-2).

TABLE 78-2 Treatment of Ankle Instability with Physiotherapy

Surgical Treatment of Recurrent Ankle Instability

After failed nonoperative treatment of ankle instability, patients may opt for surgical stabilization. The ligaments may be repaired or reconstructed. In the Broström repair, the torn ligaments are imbricated and may be augmented by the extensor retinaculum (Gould modification). Karlson modified the Broström technique by recommending repair through drill holes in bone.

Alternatively, the ligaments can be reconstructed. The reconstruction can be either anatomic or nonanatomic. Nonanatomic reconstructions include the Evans procedure (rerouting of the peroneus brevis through the fibula) or the Watson–Jones procedure (peroneal tendon weave). These reconstructions as a result sacrifice the active evertors of the ankle for a static restraint. Because the reconstruction is nonanatomic, joint motion may be restricted, so that the Evans procedure, for example, restricts subtalar joint motion.^37,³⁸ In one retrospective case–control study with long-term follow-up, the rate of arthritis, ongoing instability, and reoperation rate all favored anatomic repair over Evans tenodesis.³⁹ Nine studies recommend against the use of nonanatomic reconstructions.³⁹^–⁴⁷ Another study showed impaired kinematics after Evans tenodesis and recommended against its use.⁴² In a review of patients undergoing the Broström procedure compared with the Christman–Snook nonanatomic reconstruction, patients with the reconstruction complained of the ankle feeling “too tight.”⁴⁸ Current opinion supports the use of an anatomic reconstruction or repair without sacrifice of the active evertors of the ankle.

Anatomic Repair.

Anatomic repair (Broström repair, with or without modifications) remains one of the mainstays of surgical treatment of recurrent ankle instability.⁴⁹ Broström⁵⁰ described the imbrication of the lateral collateral ligaments. Karlsson and coworkers⁵¹ modified the Broström repair by bringing the distal segments of the ligaments through drill holes and oversewing the repair to reinforce it. Gould and investigators ⁵² modified the Broström repair by oversewing the extensor retinaculum over the top of the repaired ligaments. I prefer to use both the Karlsson and Gould modifications.⁵³ Three studies are prospective, although one study compares two postoperative regimens for one type of reconstruction.⁵⁴ The strongest study was performed by Pijnenburg and researchers,⁵⁵ a Level I, randomized, prospective study. The remainder of the studies is Level IV quality. Overall, the grade of re-commendation is B for anatomic repair of the lateral ligaments for recurrent instability. All of the studies support the anatomic reconstruction, as opposed to the significant number of studies failing to support nonanatomic reconstruction. Notably, the majority of ideal studies have been done within the anatomic repair group, with consistent results. The anatomic repair should therefore be considered the standard of care for surgical intervention of recurrent lateral ankle instability, based on the level of evidence with the current studies and outcomes available (Table 78-3).

TABLE 78-3 Surgical Treatment of Ankle Instability Using an Anatomic Lateral Ligament Repair Such as a Broström Procedure

Instability in Children.

Children and teenagers have weaker bones than adults; as a result, they are at risk for avulsing the tip of the fibula with an inversion sprain. In this case, the unstable ankle joint is associated with a fracture, providing a different pathology and a different reconstruction. The outcome of removal of the bone fragment and repair of the ligament to bone has been studied previously. The outcome studies on this procedure are summarized later in this chapter. As a subgroup of patients with ankle instabilities, they represent a small percentage of all patients with ankle instability. Notably, few patients have been studied in retrospective reviews, but all reporting good outcomes. Therefore, with a limited number of patients studied, a level C grade of recommendation exists for this procedure in children with ankle instability (see Table 78-4).

TABLE 78-4 Results for Surgery for Ankle Instability in Children

Nonanatomic Reconstruction.

Nonanatomic reconstructions are more historical interest at this time. A number of repairs have been described. The Evans repair sacrifices the peroneus brevis muscle and uses it as a static restraint on the lateral ankle by repairing the proximal end to the fibula. It is the least anatomic of the nonanatomic reconstructions. It does not reconstruct the calcaneofibular ligament and runs perpendicular to the native ligament. Patients, therefore, may describe loss of inversion range, and loss of active eversion may cause greater feeling of instability beyond the instability being treated.

The Watson–Jones reconstruction uses peroneus brevis in a similar manner to the Evans repair, but brings the tendon through the front of the fibula and also reconstructs the talofibular ligament. The Christman–Snook repair reconstructs both ligaments with peroneus brevis by bringing the tendon from front to back and making a more anatomic reconstruction of the calcaneofibular ligament.

Grade of recommendation I exists for the nonanatomic reconstructions in view of the conflicting evidence for reconstruction. A large number of articles advocate against nonanatomic reconstruction and that these procedures should not be performed, and anatomic reconstruction or repair used instead. The articles on poor outcomes of nonanatomic reconstructions support the abandonment of the procedure (Table 78-5 and 78-6).

TABLE 78-5 Outcomes of Surgery for Nonanatomic Reconstructions: Articles in Favor of the Technique

TABLE 78-6 Nonanatomic Reconstruction: The 11 Articles Reporting Poor Outcomes

Anatomic Reconstruction with Use of Allograft or Autograft Tendon Augmentation.

Anatomic reconstruction uses allograft or autograft to reconstruct the lateral collateral ligaments of the ankle in a manner that as closely as possible resembles the normal anatomy. Anatomic reconstructions preserve the function of the peroneus brevis. Like an anterior cruciate reconstruction of the knee, the anatomy cannot be completely reproduced, but the technique is designed within the limits of the surgery to resemble the normal anatomy.

Segesser ⁷⁹ and Anderson⁸⁴ have used the plantaris tendon to reconstruct the lateral collateral ligaments. A drill hole is made through the calcaneus to deliver the tendon at the insertion of the calcaneofibular ligament. The tendon is then brought up through drill holes in the fibula and back onto the insertion of the anterior talofibular ligament, repairing to the talus with drill holes. Colville ⁸⁰ repaired the lateral ligaments using half of peroneus brevis, thus preserving the function of the brevis muscle as an evertor. Coughlin⁸³ uses a free gracilis graft through drill holes. A modification of the Anderson technique using a free gracilis autograft is our preferred technique for lateral ligament reconstruction. No outcome review has been performed to date.⁷⁸

All articles to date support the concept of an anatomic reconstruction. Some surgeons select the anatomic reconstruction for patients with more attenuated tissue. Because these tendon autograft or allograft lateral ligament reconstruction are newer techniques, limited outcome data are available. However, all articles support of anatomic reconstruction with a grade C recommendation (see Table 78-7).

TABLE 78-7 Outcomes of Anatomic Reconstruction with Autograft or Allograft Tendon

Revision Lateral Ligament Reconstruction.

Only two articles identified the outcome of lateral ligament reconstruction for revision of a previous failed repair. As would be expected, few articles have been published in this area. Those two articles support the principle with a grade C recommendation, with the caution that few patients have been studied. Table 78-9 provides a summary of recommendations for the treatment of recurrent ankle instability.

TABLE 78-9 Summary of Recommendations

STATEMENT	LEVEL OF EVIDENCE/GRADE OF RECOMMENDATION	REFERENCES
1. Acute ankle sprains should be treated non operatively.

B 8–11, [1]

2. Brace treatment may be effective for non operative treatment of ankle instability.

C 19–27

3. Physiotherapy is beneficial for patients with recurrent ankle instability.

B 26,28–36

4. For failed non operative treatment a Brostrom repair of the ligaments is effective, including Karlsson and Gould Modifications.

B 55–63

5. There is insufficient research to determine the best treatment for ankle instability in children, although studies to date show benefit.

C 64–66

6. Non anatomic reconstructions of the ankle are not recommended due to the large number of papers documenting poor outcomes with Evans and Watson Jones Procedures.

C 39,47,76,77

7. There is insufficient evidence to support non anatomic reconstructions.

C 37, 47, 68–75

8. Anatomic reconstruction should be used if a repair cannot be performed because of poor or insufficient residual ligaments.

C 79–84

9. There is insufficient evidence for the use of anatomic reconstruction as a primary procedure.

C 79–84

TABLE 78-8 Outcomes of Revision Lateral Ligament Reconstruction

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