Improved Outcome and Earlier Return to Activity After Suture Tape Augmentation Versus Broström Repair for Chronic Lateral Ankle Instability? A Systematic Review

SLR - January 2022 - Kevin Nguyen

Reference: Wittig U, Hohenberger G, Ornig M, Schuh R, Reinbacher P, Leithner A, Holweg P. Improved Outcome and Earlier Return to Activity After Suture Tape Augmentation Versus Broström Repair for Chronic Lateral Ankle Instability? A Systematic Review. Arthroscopy. 2021 Jul 9:S0749-8063(21)00652-6.

Level of Evidence: III

Scientific Literature Review

Reviewed By: Kevin Nguyen, DPM
Residency Program: OhioHealth Grant Medical Center – Columbus, OH

Podiatric Relevance: Lateral ankle sprains are the most common sports injury with about 10-20 percent of patients developing chronic lateral ankle instability (CLAI). The modified Broström (MB) procedure has been the mainstay of operative treatment in CLAI. Biomechanical studies have demonstrated that reconstruction of the anterior talofibular ligament (ATFL) does not achieve the strength of the native ligament, thus, aggressive post-operative rehabilitation protocols should be avoided. Suture tape augmentation (STA) acts as an “internal brace” to protect the repaired ligament during healing. The aim of this study was to determine whether the use of STA would improve clinical outcomes, increase stability, lead to shorter post-operative immobilization, and earlier return to activity when compared with MB alone.

Methods: A systematic literature review was performed using Pubmed and Embase with the final search date on February of 2021. The search terms were “ankle instability” AND “suture tape” or “fiber tape” or “internal brace”. The inclusion criteria was clinical trials directly comparing STA and MB in the treatment of CLAI, English full texts, and a minimum cohort of 40 patients. The exclusion criteria comprised of former systematic reviews, cadaveric or biomechanical studies, and case reports. This study ultimately included seven articles after excluding 55 studies. Of the included articles, four were randomized controlled trials and three were retrospective cohort studies. Clinical patient reported outcome scores, radiologic outcomes, post-operative treatment, and return to activity from each study were recorded and compared.

Results: Four of the studies implemented the same rehabilitation protocols. Kulwin et al. and Porter et al. utilized an accelerated rehabilitation method and allowed weightbearing as tolerated following surgery. Kulwin et al. proved that return to the pre-operative level was significantly faster after STA. Recurrence of instability and revision tended to occur more after MB, whereas irritation of nerve and tendons appeared to occur more frequently after STA. The overall complication rate and risk for wound infection was slightly higher after MB. Two of the studies found that return to activity was significantly faster after STA, this was contrary to one study that was performed with an all-arthroscopic MB compared to an open STA.

Conclusions: Clinical and radiologic outcomes did not statistically differ between the MB and STA groups. The MB group did, however, appear to develop a higher rate of recurrence and wound complication, although not with statistical significance. In studies where rehabilitation protocols differed, STA allowed earlier return to full weightbearing and a shorter period of immobilization. The findings of the studies demonstrate that arthroscopic MB performed procedures may be a variable allowing accelerated rehabilitation compared with open techniques. The authors hypothesized that STA could improve stability of the ATFL during healing and thus allow a quicker weightbearing and return to activity. In conclusion, STA is a safe technique that allows for a quicker return to activity than MB but with potentially more subsequent nerve and tendon irritation. However, both techniques demonstrate similar clinical and radiologic outcomes. STA may be beneficial for active patients and those who may benefit from accelerated rehabilitation.