Outcomes of Adding Inferior Extensor Retinaculum Reinforcement to Arthroscopic Anterior Talofibular Ligament Repair: A Systematic Review and Meta-Analysis

Abstract

Background:

Arthroscopic anterior talofibular ligament (ATFL) repair procedures generally involve either repair solely of the ATFL or repair of the ATFL with inferior extensor retinaculum (IER) reinforcement. Both techniques produce strong clinical outcomes; however, studies directly comparing ATFL repair techniques with and without IER reinforcement are limited. We hypothesize that patients receiving arthroscopic ATFL repair with IER reinforcement have superior clinical outcome scores.

Methods:

A systematic review and meta-analysis per PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines was conducted. To assess the relationship of type of surgical procedure (repair of only the ATFL or repair of the ATFL plus IER reinforcement) to reported clinical outcomes based on the Karlsson and Peterson Scoring System for Ankle Function (KAFS), visual analog scale (VAS), and the American Orthopaedic Foot & Ankle Society (AOFAS) score, we used the standardized mean difference (SMD) with a 95% CI of preoperative to postoperative scores as an effect size. A meta-regression analysis was conducted to identify the source of differences in the observed effect size between studies.

Results:

A total of 638 studies met the initial search criteria. The meta-analysis included 34 studies to compare clinical outcomes of arthroscopic ATFL repair. Arthroscopic ATFL repair both with and without IER reinforcement resulted in significantly improved preoperative to postoperative clinical outcome scores. Arthroscopic ATFL repair with IER reinforcement resulted in a significantly higher preoperative to postoperative SMD for KAFS (P = .091) and VAS (P = .065) scores compared to arthroscopic ATFL repair without IER reinforcement. There was no significant difference in the preoperative to postoperative SMD of AOFAS (P = .453) scores when comparing surgical procedures. ATFL repair with IER reinforcement had a significantly greater rate of superficial peroneal nerve (SPN) injury (P = .004).

Conclusion:

Arthroscopic ATFL repair with IER reinforcement leads to improved clinical outcome scores but carries a higher risk of SPN injury compared to arthroscopic ATFL repair without IER reinforcement. Patients receiving either arthroscopic procedure should achieve excellent functional outcomes.