Functional outcomes of all-inside arthroscopic anterior talofibular ligament repair with loop suture versus free-edge suture

Ankle injuries are common in all sports, and inversion injury of the ankle is the most frequent ankle injury 1,2,3,4,5]. The anterior talofibular ligament (ATFL), calcaneofibular ligament and posterior talofibular ligament are the main ligament structures to maintain the stability of the lateral ankle joint. Injuries to the ATFL account for about 62% of the injuries to the lateral ankle ligament complex [6, 7]. After 3 to 6 months of appropriate conservative treatment and rehabilitation, most patients with ATFL injury can regain satisfactory functional results [8]. However, even after appropriate rehabilitation, residual lateral ankle pain, repeated ankle sprain and giving way are observed in 10% to 12% of the patients, who develop chronic lateral ankle instability (CLAI) [1, 9]. Surgical management is recommended for symptomatic CLAI [10, 11].

Anatomical repair of the ATFL is the mainstay of surgical strategies in CLAI management [12]. Satisfactory functional outcomes are obtained following open surgery, and, when the procedure is preceded by arthroscopic surgery, intra-articular lesions can be successfully managed [13, 14]. Recently, arthroscopic management of the ligamentous lesions of the ankle has become more popular 15,16,17]. The ankle joint is a major load-bearing joint of the lower limb, and compressive stresses during sport and exercise can reach 3 to 5 times the body weight [1]. Arthroscopic surgical procedures are however more technically challenging, and different suture configurations are in use. To date, loop suture and free-edge suture configurations are both used for arthroscopic ATFL repair [10, 18]. However, there are few publications addressing the issue of differences in functional results between the use of loop suture and free-edge suture.

The purpose of this study was to compare the clinical results in terms of ankle function, stability and proprioceptive recovery in 71 patients with CLAI treated by all-inside arthroscopic ATFL repair using loop suture or free-edge suture in our department from February 2016 to July 2018.

We wished to test the null hypothesis of no difference in outcome of the two arthroscopic suture configurations in patients with CLAI.

Patients and methods

The institutional review boards of our hospital approved the study. The study was a retrospective cohort study evaluating the outcomes of patients undergoing arthroscopic anatomical repair of ATFL with either loop suture or free-edge suture configuration. All patients provided a signed informed consent as well as consents for the Health Insurance Portability and Accountability Act to participate in this study.

Patient selection

We included patients who satisfied the following criteria: (1) skeletally mature patients who were diagnosed with CLAI after failure of at least 6 months of conservative management; (2) patients with giving way, and ankle sprained more than twice in the previous 6 months; (3) positive pre-surgery anterior drawer test [19]; (4) pre-operative Magnetic Resonance Imaging show injury of the ATFL (Fig. 1A); (5) patients with unilateral ankle ATFL injury (non-avulsed fracture) but no calcaneofibular ligament injury (confirmed at arthroscopy) (Fig. 1B); (6) patients who had received all-inside arthroscopic ATFL repair procedure using the loop suture or free-edge suture configuration; (7) patients with complete surgical and follow-up data, followed up for at least 12 months.

Fig. 1figure 1

ATFL injury confirmed at the magnetic resonance imaging (A) and arthroscopy (B)

We excluded patients who satisfied the following criteria: (1) patients with generalized ligamentous laxity; (2) patients who presented CLAI combined with foot and ankle deformity, abnormal hindfoot alignment, previous foot and ankle surgery, and other ligament injuries; (3) patients with osteochondral injury greater than 15 mm in diameter in any direction, or which required osteochondral transplantation, or in whom CLAI was associated with ankle osteoarthritis/ talar cyst; (4) patients with an os subfibulare; (5) patients with severe comorbidities who could not tolerate the surgery; (6) patients who suffered secondary injury of the ankle or who underwent revision surgery.

Participants

From February 2016 to July 2018, 164 consecutive CLAI patients underwent all-inside arthroscopic ATFL repair with loop suture configuration or free-edge suture configuration by a senior surgeon with extensive experience in foot and ankle surgery. A total of 93 patients did not meet the inclusion criteria and were excluded. Of these patients, 45 were lost during the postoperative follow-up period. The follow-up period was less than 12 months in 28 patients, and the ATFL injury was combined with other injuries in 20 patients. A total of 71 patients satisfied our inclusion criteria and were enrolled in the present study (Fig. 2).

Fig. 2figure 2

Flow diagram of the study

After communication (suture fashion, operative time, currently reported outcomes) with the doctor, patients were invited to choose between the free-edge configuration or the loop configuration. The patients who were undecided tossed a coin and were allocated to undergo one or the other technique.

Patients were divided into two groups based on the ATFL suture configuration. In a total of 36 patients the ATFL was sutured using a loop configuration. In the remaining 35 patients, a free-edge configuration was used to suture the ATFL.

In the loop suture group, there were 22 male patients and 14 female patients, aged 19 to 52 years (average age, 33.83 years). The injury occurred during sports (n = 25) or following traffic accidents (n = 11). The right ankle was involved in 23 patients, and left ankle in 13 patients. The procedure was performed after a mean duration of 15.75 ± 3.16 months (range, 12–22 months) from the index injury. In the free-edge suture group, there were 20 male patients and 15 female patients, aged 18 to 54 years (average age, 35.71 years). The injury occurred during sports (n = 24) or following traffic accidents (n = 11). The right ankle was involved in 20 patients, and the left ankle in 15 patients. The procedure was performed after a mean of 15.63 ± 2.84 months (range, 12–22 months) from the index injury (Table 1).

Table 1 Characterization of the SampleSurgical technique

With the patient supine on the operating table, general anesthesia and lumbar plexus-sciatic nerve block were performed. A 7 cm pillow was placed under the ipsilateral hip, and the affected ankle was placed over the distal edge of the operating table. A pneumatic tourniquet was placed at the root of the thigh and inflated to 300 mmHg after exsanguination.

A standard anteromedial viewing portal was established, and intra-articular lesions were evaluated arthroscopically. Under direct arthroscopic vision, an anterolateral portal was established lateral to the peroneus tertius. The intra-articular lesions were managed using a 3.5 mm shaver inserted through this portal, and the ATFL footprint on the fibula was exposed. The cartilage of the talus was evaluated by gentle probing. The ATFL was identified and its tension and quality were assessed. An anterior subtalar portal was produced if the ATFL was difficult to identify and assess. A bleeding bony surface at the footprint region of the fibula was produced using a motorized burr. To protect the remnant of the ATFL, a polydioxanone suture can be used to pull the ATFL. A double loaded suture anchor (Fastin RC 3.5 mm, Smith & Nephew, Andover, MA) was inserted into the mid-portion of the footprint through the anterior subtalar portal or an accessory anterolateral portal. The anchor was inserted at an angle of 30° to 45° from the longitudinal axis of the fibula. The proximal remnant of the ATFL was grasped with a grasper, and maintained under gentle tension. The ATFL was sutured using a loop (Fig. 3 and Fig. 4) or a free-edge configuration [10] (Fig. 5). Finally, after confirming under arthroscopic vision that the suture held, the suture limbs were sutured with a knot pusher with the ankle slightly dorsiflexed and everted. The anterior drawer test and the ankle varus stress test were performed under direct arthroscopic vision. After confirming that the sutures held, the arthroscope was withdrawn and the incision was closed with a 3–0 monofilament.

Fig. 3figure 3

Surgical diagrams of all-inside arthroscopic ATFL repair with loop suture configuration (one suture arm sutured). A and B: one suture arm (purple) was passed through the distal ATFL remnant and a loop was created in the lateral gutter. C and D: the free end of the suture arm (purple) was passed through the created loop, and the ATFL would be self-cinching sutured when the free suture arm was pulled

Fig. 4figure 4

Surgical diagram of all-inside arthroscopic ATFL repair with loop suture configuration (two suture arms sutured)

Fig. 5figure 5

Surgical diagram of all-inside arthroscopic ATFL repair with free-edge suture configuration

Postoperative management

A total of three doses of antibiotics were administered within 24 h after the operation. A short leg brace was used to immobilize the ankle joint for 2 weeks in slight dorsiflexion and eversion. Patients performed functional exercises under the guidance of a physical therapist. On the second day after surgery, patients were advised to perform gentle non-weight-bearing mobilization isometric exercises of the lower limb muscles. Two weeks later, weight-bearing functional exercises were initiated, and an AircastTM (DJO, Vista, CA, USA) boot was used. Physical activities were encouraged after removing the Aircast boot 6 weeks later.

Postoperative follow-up and observational indexes

All the patients were followed up as outpatients. All the postoperative indexes were recorded at each follow-up appointment after the index surgery. The surgical duration, hospital stay duration, wound healing and complications were recorded. The anterior drawer test was performed and compared with the uninjured limb. The visual analog score (VAS), American Orthopedic Foot and Ankle Society scoring system (AOFAS), Karlsson Ankle Functional Score (KAFS) scoring system and Anterior Talar Translation (ATT) were administered to assess ankle function and therapeutic efficacy. Ankle proprioception was assessed using the Active Joint Position Sense (AJPS) [20]. The realization of AJPS: with the patients seated on a height-adjustable table, the affected lower limb was placed at a 90° angle from the hip, knee, and ankle, respectively. At the assistance of the footplate, the operated ankle was passively placed in 10° and 20°of inversion and plantar flexion, respectively. Patients were then asked to actively place the foot in the above positions. Every position was tested three times, and the average value was observed. All the above outcomes were evaluated by the same experienced ankle surgeon who did not participate in the index surgery, and was blinded to the procedure performed.

Statistical analysis

The SPSS 19.0 statistical software was used for analysis. Quantitative variables were expressed as means and standard deviations. Surgical duration, hospital stay duration, VAS, AOFAS, KAFS, ATT and AJPS scores in the two groups were compared and analyzed using the t test (symmetric distribution) or the Mann–Whitney test (asymmetric distribution). The Pearson chi-square test was used to compare the categorical variables. A post hoc power analysis was performed. A difference of p < 0.05 was deemed as statistically significant.

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