Abstract
Research Type:
Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies
Introduction/Purpose:
Lateral ankle ligament injuries are common in athletes, often leading to chronic instability, primarily due to ATFL damage. The Broström procedure has long been the gold standard, but advancements in arthroscopic techniques offer a viable alternative. While initially described in the 1990s, minimally invasive arthroscopy has gained traction with improved instruments and techniques. Comparative studies on open vs. arthroscopic ATFL repair have grown, but findings remain inconsistent. Earlier reviews reported higher complications with arthroscopy, while recent meta-analyses suggest the opposite. Disparities exist in functional outcomes, operative metrics, and PROs. This systematic review and meta-analysis aims to provide the most comprehensive comparison between open and arthroscopic approaches for treating CLAI, to better guide physicians in managing this common injury.
Methods:
This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). utilizing PubMed, Scopus, MEDLINE, CINAHL, and Web of Science databases from inception until June 6th, 2024.
Article quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) scale. Inclusion criteria included studies that directly compared open Broström and arthroscopic ATFL reconstruction in adult patients, were in English, and had full-text available for review. Exclusion criteria included non-comparative studies, reviews, case reports, abstracts, and cohorts of less than 5 patients. Data extraction included patient demographics, preoperative and postoperative clinical and radiographic outcomes, patient reported outcome scores (e.g., VAS, AOFAS, FAOS, SF-36) and complication rates. Statistical analyses were performed using both common-effect and random-effect models.
Results:
Out of 1,359 articles retrieved, 23 met inclusion criteria, with an average MINORS score of 20.05/24. Among these, 21 were scored as high-quality evidence, and the remaining 2 were moderate-quality. The studies included 1,304 patients (618 open, 686 arthroscopic). The arthroscopic group was significantly older (34.22 vs. 31.80 years, p< 0.001) and had a shorter time from injury to surgery (14.29 vs. 19.47 months, p< 0.001). Pre-operative radiographic measurements showed no significant differences, though post-operative talar tilt favored open treatment (p < 0.0001). Functional scores were similar pre-operatively but post-operative AOFAS and Karlsson-Peterson scores favored arthroscopy (p < 0.05). Surgical time and overall complications were comparable, but open surgery had higher wound healing issues (15.02% vs. 7.60%, p=0.035).
Conclusion:
In this systematic review and meta-analysis, treatment of chronic ankle instability via arthroscopic or traditional, open Broström approaches yielded no significant clinical difference. While overall complication rates were similar, wound healing favored the arthroscopic treatment group. Future comparative research with robust randomized controlled trials is necessary to fully address the differences between the two approaches, but this study provides the most comprehensive comparison to date, suggesting that outcomes appear clinically similar, but the arthroscopic technique may be associated with a lower rate of complications.
Forest Plots of AOFAS, Karlsson-Peterson, Operative Time, and Complications
Forest plots comparing outcomes of Arthroscopic vs. Open Broström Technique: A. Post-operative AOFAS Scores, B. Post-operative Karlsson-Peterson Scores, C. Operative Time, and D. Complication Rates.