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Surgical repair of grade 3 lateral ligament ankle ruptures reduces re-injury
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March 2013
Surgical repair of grade 3 lateral ligament ankle ruptures reduces re-injury
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
Surgical versus functional treatment for acute ruptures of the lateral ligament complex of the ankle in young men: A randomized controlled trial
J Bone Joint Surg Am. 2010 Oct 20;92(14):2367-74. Epub 2010 Sep 10.Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
51 physically active Finnish men with the acute rupture of the lateral ligament of the ankle were randomized to be treated with either the surgical repair and accelerated functional treatment or with traditional functional treatment using Aircast ankle brace. The long-term results of surgical treatment of acute lateral ligament rupture of the ankle corresponded well with functional treatment modalities alone; however, the surgical treatment had a lower re-rupture incidence, but was associated with higher rates of osteoarthritis of the ankle joint.
Publication Funding Details
+
Funding:
Non-funded
Conflicts:
None disclosed
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
3/4
Randomization
3/4
Outcome Measurements
4/4
Inclusion / Exclusion
4/4
Therapy Description
1/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Lateral ligament ankle injuries are very common with over 300,000 cases reporting annually to emergency rooms in UK alone. The treatment of acute ruptures of the lateral ligaments is a controversial issue with insufficient evidence to compare surgical and non-surgical modalities. Previous studies have shown notable design flaws, such as short follow-ups, faulty randomizations, and heterogeneous study samples. This study evaluated the long term outcomes of the surgical vs non-surgical approaches.
What was the principal research question?
Does the surgery provide better long-term outcomes than a purely functional rehabilitation for the grade 3 lateral ankle ruptures?
Study Characteristics
-
Population:
51 physically active male conscripts in Finnish Defense Forces (age range 18 to 26) with grade 3 rupture of lateral ankle ligament less than 6 days old
Intervention:
Surgical Group: Surgical Repair of the acute ruptures of lateral ligaments of ankle was performed within the first week after injury, followed by below knee plaster cast worn for 6 weeks with full weight bearing (n=25)
Comparison:
Functional Group: Functional Rehabilitation was performed with an Aircast ankle brace for 3 weeks (n=26)
Outcomes:
Performance Test Protocol and Scoring Scale for Evaluation of Ankle Injuries, Ankle Scoring, Stress Radiographs, MRI imaging, objective instability (anterior drawer, talar tilt), range of motion, return visits, and return to preinjury level of physical activity
Methods:
Prospective RCT: Double Blind
Time:
6 weeks, 3 months, 3-4 years, 14-15 years (mean follow up of 14 years)
What were the important findings?
- The prevalence of reinjury was 1/15 in the surgical group and 7/18 in the functional treatment group (risk difference: 32%; 95% confidence interval: 6% to 58%).
- The mean ankle score on Performance Test Protocol and Scoring Scale for the Evaluation of Ankle Injuries was not significantly different between the groups (mean difference: 8.3 points; 95% confidence interval:-0.03 to 16.6 points)
- Stress radiographs showed no differences between groups, with regard to the mean anterior drawer (1 mm in the surgical group and 0 mm in the functional group; mean difference: 0.7 mm; 95% confidence interval:1.4 to 2.7 mm) or mean tilt angle (0 degrees in both groups; mean difference: 0.1 degrees; 95% confidence interval: 3.2 degrees to 3.5 degrees)
- Grade-II osteoarthritis was observed on magnetic resonance images of 4/15 surgically treated patients and 0/18 for the functionally treated patients (risk difference: 27%; 95% confidence interval: 4% to 49%)
- 10/15 patients in the surgical group and 7/18 in functional group subjectively reported complete recovery (risk difference: 28%; 95% confidence interval: -5% to 61%). All patients in both groups recovered to preinjury activity level (walk and run normally)
- The level of physical activity, range of motion compared to contralateral ankle, and number of patients visiting a physician at the time of follow-up did not differ between the two groups.
- 3/15 surgical patients had loss of sensation in the lateral aspect of ankle and foot. No re-operations due to ankle instability, infections, or incidences of venous thrombosis were seen in either group.
What should I remember most?
The recovery to preinjury levels of acute lateral grade III ligament rupture of the ankle was equivalent when using either surgical or nonoperative methods. Re-injury was significantly less in surgical group; however, there was significantly more OA present.
How will this affect the care of my patients?
This study questions whether to subject patients to surgical risks given the evidence of equal pre-injury recovery, and suggests that non-surgical treatments can be equally beneficial. However, larger sample sizes are needed to confirm these findings.
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Orthopaedic Surgeon - United States
no surgery !