Does Lateral Ankle Stabilization Need to Be Augmented?

Ankle sprains continue to be among the most commonly treated injuries by foot and ankle surgeons today. Since roughly 25% of all ankle sprains lead to chronic instability, the surgical management advancements used to treat these injuries have been critical to improved outcomes.¹ The traditional Broström procedure was originally described for an anatomic repair of the anterior talofibular ligament (ATFL). In 1980, the Gould modification was added to increase stabilization of the lateral ankle and the subtalar joint. With continued advancements in technology, augmentation has moved to the forefront of treatment for lateral ankle stabilization.

For this discussion in augmentation versus non-augmentation of the lateral ankle, we first need to define the pathology we are trying to treat. In patients with minimal instability and an intact lateral ligament, augmentation is not typically required. For the purpose of this article, I will be discussing patients with chronic instability and magnetic resonance image (MRI) findings consistent with damaged anterior talofibular ligaments.

A Closer Look at Augmentation Technology and Technique

The use of augmentation may be defined in several different facets, including soft tissue anchors as well as more advanced restrictive devices such as suture tape and dynamic matrix biomaterials. As technology continues to advance in foot ankle surgery, so does technique. Arthroscopic lateral ankle repair using suture anchor augmentation has demonstrated success when compared to a traditional open approach.²

In review of the current literature, it is noted that the use of augmentation in ankle stability is the standard treatment plan. I feel this is due to the lack of tissue continuity in high-level ankle sprains. Type I collagen continues to degrade in chronic ankle sprains leading to type II collagen and fibrous tissue formation during the healing phase. A traditional Broström/Broström-Gould procedure relies on robust tissue cuff for the repair, which is typically not present in the chronic ankle sprain.   

In a systematic review, Piscoya et al³ demonstrate that a modified Broström with suture tape augmentation for chronic lateral ankle instability can produce good short-term clinical outcomes with few complications, as compared to the modified Broström alone. The modified Broström has been extensively studied in both cadaveric and prospective studies. In a cadaver model, suture tape augmentation of native ATFL resulted in “an approximately 50% higher mean load to failure and stiffness compared with the intact ATFL.”^4-6

Historically, patients with lateral ligament reconstructions were immobilized for extended periods of time prior to engaging in physical therapy. This was due to the belief that the native ligament needed to scar down in order to provide stability to the lateral ankle. One of the most important advances in the treatment of ligament injuries has come from the understanding that controlled early resumption of activity can stimulate repair and restoration of function, and that treatment of ligament injuries with prolonged rest may delay recovery and adversely affect the tissue repair.⁷ With increased stability and strength, foot and ankle surgeons are more willing to challenge the limits for postoperative recovery in lateral ligament reconstruction when augmentation has been utilized.  

Coetzee et al⁸ reported that the 81 patients in their study demonstrated excellent improvement in function along with reduction in pain. The patients experienced an average return to play within 84 days of an augmented ligament repair. Porter et al⁹ later noted that among physically active patients with chronic lateral ligament instability, primary repair combined with the ligament augmentation reconstruction system (LARS) resulted in a better total Foot and Ankle Orthopedic Scores (FAOS) at the 5-year follow-up and higher Tegner activity scores as compared with the modified Broström-Gould procedure.

The use of biomaterial matrix is gaining traction in the foot and ankle space as well. A flexible matrix allows for tensioning of the lateral ankle without constraining the ankle joint. These flexible materials mirror the normal kinematics required of the ATF ligament during gait. Ongoing research demonstrates appropriate stability of these grafts with low complication rates in foot and ankle surgery.¹⁰

In Conclusion

Technology has continued to evolve in the foot and ankle space which has allowed surgeons to obtain reproducible results for lateral ankle stabilization. The use of augmentation allows for strengthening of the lateral ankle when the soft tissue alone is dysmorphic. Despite the increase in cost of these implants, early mobilization and reduced revision rates continue to be noted throughout the literature.

Dr. Scott is a fellowship Trained Foot and Ankle Surgeon. He is the Fellowship Director of the CORE Institute Advanced Foot and Ankle Reconstruction Fellowship in Phoenix.

References

1.    Waterman BR, Owens B, Davey S, Zacchilli MA, Belmont PJ. The epidemiology of ankle sprains in the United States. JBJS. 2010; 92(16):2279–2284.
2.    Rigby R, Cottom JM. A comparison of the “all-inside” arthroscopic Broström procedure with the traditional open modified Broström Gould technique: a review of 62 patients. Foot Ankle Surg. 2019; 25(1):31–36.
3.    Piscoya AS, Bedrin MD, Lundy AE, Eckel TT. Modified Broström with and without suture tape augmentation: A systemic review. J Foot Ankle Surg. 2022; 61(2):390–395.
4.    Viens NA, Wijdicks CA, Campbell KJ, Laprade RF, Clanton TO. Anterior talofibular ligament ruptures, part 1: biomechanical comparison of augmented Broström repair techniques with the intact anterior talofibular ligament. Am J Sports Med. 2014;42(2):405–411.
5.    Schuh R, Benca E, Willegger M, et al. Comparison of Broström technique, suture anchor repair, and tape augmentation for reconstruction of the anterior talofibular ligament. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1101–1107.
6.    Willegger M, Benca E, Hirtler L, et al. Biomechanical stability of tape augmentation for anterior talofibular ligament (ATFL) repair compared to the native ATFL. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1015–1021.
7.    Hauser RA, Dolan EE. Ligament injury and healing: An overview of current clinical concepts. J Prolo. 2011; 3(4):836–846.
8.    Coetzee JC, Ellington JK, Ronan JA, Stone RM. Functional results of open Broström ankle ligament repair augmented with a suture tape. Foot Ankle Int. 2018; 39(3):304–310.
9.    Porter M, Shadbolt B, Ye Z, Stuart R. Ankle lateral ligament augmentation versus the modified Broström-Gould procedure. Am J Sports Med. 2019; 47(3):659–666.
10.    Kelly MJ, Dean DM, Hussaini SH, Neufled SK, Cuttica DJ. Safety profile of synthetic elastic degradable matrix for soft tissue reconstruction in foot and ankle surgery. Foot Ankle Spec. 2021. https://doi.org/10.1177/19386400211067627