Review of Variability in Rehabilitation Protocols after Lateral Ankle Ligament Surgery

Category: Ankle; Sports Introduction/Purpose: Ankle sprains are one of the most common athletic injuries. If a patient fails to improve through conservative management, surgery is an option to restore ankle stability. The purpose of this study is to analyze the variability across rehabilitation for patients undergoing lateral ankle ligament repair, reconstruction, or suture tape augmentation. Methods: 26 protocols were found. Inclusion criteria was protocols for ankle ligament surgery. Protocols for nonoperative care were excluded. A rubric was created to analyze weightbearing, range of motion (ROM), immobilization, single leg exercises, return to running, and return to sport (RTS). Results: There was variability especially in recommendations for immobilizing brace, partial and full weigh bearing, specific ROM movements of the ankle, and return to single leg exercise and running. For repair and reconstruction, none of these categories had greater than 60% agreement. 100% (12/12) of repair and 86% (12/14) of reconstruction protocols recommended no ROM postoperatively, and 86% (6/7) repair and 78% (11/14) reconstruction recommended no weightbearing postoperatively, making postoperative ROM and weightbearing status the most consistent aspects across protocols. Suture tape augmentation protocols generally allowed rehabilitation on a quicker timeline with full weightbearing by week 4-6 in 100% (3/3) of protocols and full ROM by week 8-10 in 66% (2/3). RTS was consistent in repair protocols (100% at week 12-16). Conclusion: ROM was variable across protocols and did not always match up with supporting literature. Return to sport was likely to correlate between protocols and the literature. Weightbearing was consistent between protocols. The variability between programs demonstrated the need for standardization of rehabilitation.

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Review of Variability in Rehabilitation Protocols after Lateral Ankle Ligament Surgery

Kansas Journal of Medicine ◽

10.17161/kjm.v13i.13820 ◽

2020 ◽

Vol 13 ◽

pp. 152-159 ◽

Cited By ~ 1

Author(s):

Christina Hermanns ◽

Reed Coda ◽

Sana Cheema ◽

Matthew Vopat ◽

Megan Bechtold ◽

...

Keyword(s):

Weight Bearing ◽

Return To Sport ◽

Full Weight Bearing ◽

Ligament Repair ◽

Lateral Ankle ◽

Operative Care ◽

Ankle Ligament ◽

Rehabilitation Protocols ◽

Lateral Ankle Ligament ◽

Suture Tape

Introduction. Ankle sprains are one of the most common athletic injuries. If a patient fails to improve through conservative management, surgery is an option to restore ankle stability. The purpose of this study was to analyze and assess the variability across different rehabilitation protocols for patients undergoing either lateral ankle ligament repair, reconstruction, and suture tape augmentation. Methods. Using a web-based search for published rehabilitation protocols after lateral ankle ligament repair, reconstruction, and suture tape augmentation, a total of 26 protocols were found. Inclusion criteria were protocols for post-operative care after an ankle ligament surgery (repair, reconstruction, or suture tape augmentation). Protocols for multi-ligament surgeries and non-operative care were excluded. A scoring rubric was created to analyze different inclusion, exclusion, and timing of protocols such as weight-bearing, range of motion (ROM), immobilization with brace, single leg exercises, return to running, and return to sport (RTS). Protocols inclusion of different recommendations was recorded along with the time frame that activities were suggested in each protocol. Results. Twenty-six protocols were analyzed. There was variability across rehabilitation protocols for lateral ankle ligament operative patients especially in the type of immobilizing brace, time to partial and full weigh bearing, time to plantar flexion, dorsiflexion, eversion and inversion movements of the ankle, and return to single leg exercise and running. For repair and reconstruction, none of these categories had greater than 60% agreement between protocols. All (12/12) repair, internal brace, and unspecified protocols and 86% (12/14) of reconstruction protocols recommended no ROM immediately postoperatively. Eighty-six percent (6/7) of repair and 78% (11/14) of reconstruction protocols recommended no weight-bearing immediately after surgery, making post-operative ROM and weight-bearing status the most consistent aspects across protocols. Five protocols allowed post-operative weight-bearing in a cast to keep ROM restricted. Sixty-six percent (2/3) of suture tape augmentation protocols allowed full weight-bearing immediately post-operatively. Suture tape augmentation protocols generally allowed rehabilitation to occur on a quicker time-line with full weight-bearing by week 4-6 in 100% (3/3) of protocols and full ROM by week 8-10 in 66% (2/3) protocols. RTS was consistent in repair protocols (100% at week 12-16) but varied more in reconstruction. Conclusion. There is significant variability in the post-operative protocols after surgery for ankle instability. ROM was highly variable across protocols and did not always match-up with supporting literature for early mobilization of the ankle. Return to sport was most likely to correlate between protocols and the literature. Weight-bearing was consistent between most protocols but requires further research to determine the best practice. Overall, the variability between programs demonstrated the need for standardization of rehabilitation protocols.

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Review of Variability in Rehabilitation Protocols after Lateral Ankle Ligament Surgery

Arthroscopy The Journal of Arthroscopic and Related Surgery ◽

10.1016/j.arthro.2020.12.153 ◽

2021 ◽

Vol 37 (1) ◽

pp. e74-e75

Author(s):

Christina Hermanns ◽

Reed Coda ◽

Sana Cheema ◽

Matthew Vopat ◽

Megan Bechtold ◽

...

Keyword(s):

Lateral Ankle ◽

Ankle Ligament ◽

Rehabilitation Protocols ◽

Lateral Ankle Ligament

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Biomechanics of Ankle Ligament Reconstruction: A Cadaveric Study to Compare Stability of Reconstruction Techniques Using 1 or 2 Fibular Tunnels

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120959284 ◽

2020 ◽

Vol 8 (10) ◽

pp. 232596712095928

Author(s):

Martina Gautschi ◽

Elias Bachmann ◽

Camila Shirota ◽

Tobias Götschi ◽

Niklas Renner ◽

...

Keyword(s):

Ligament Reconstruction ◽

Ankle Instability ◽

Intraoperative Complications ◽

Lateral Ankle ◽

Ankle Stability ◽

Ankle Ligament ◽

Significant Difference ◽

Tunnel Technique ◽

Lateral Ankle Ligament ◽

Lateral Ankle Ligament Reconstruction

Background: Anatomic lateral ankle ligament reconstruction has been proposed for patients with chronic ankle instability. A reliable approach is a reconstruction technique using an allograft and 2 fibular tunnels. A recently introduced approach that entails 1–fibular tunnel reconstruction might reduce the risk of intraoperative complications and ultimately improve patient outcome. Hypothesis: We hypothesized that both reconstruction techniques show similar ankle stability (joint laxity and stiffness) and are similar to the intact joint condition. Study Design: Controlled laboratory study. Methods: A total of 10 Thiel-conserved cadaveric ankles were divided into 2 groups and tested in 3 stages—intact, transected, and reconstructed lateral ankle ligaments—using either the 1– or the 2–fibular tunnel technique. To quantify stability in each stage, anterior drawer and talar tilt tests were performed in 0°, 10°, and 20° of plantarflexion (anterior drawer test) or dorsiflexion (talar tilt test). Bone displacements were measured using motion capture, from which laxity and stiffness were calculated together with applied forces. Finally, reconstructed ligaments were tested to failure in neutral position with a maximal applicable torque in inversion. A mixed linear model was used to describe and compare the outcomes. Results: When ankle stability of intact and reconstructed ligaments was compared, no significant difference was found between reconstruction techniques for any flexion angle. Also, no significant difference was found when the maximal applicable torque of the 1-tunnel technique (9.1 ± 4.4 N·m) was compared with the 2-tunnel technique (8.9 ± 4.8 N·m). Conclusion: Lateral ankle ligament reconstruction with an allograft using 1 fibular tunnel demonstrated similar biomechanical stability to the 2-tunnel approach. Clinical Relevance: Demonstrating similar stability in a cadaveric study and given the potential to reduce intraoperative complications, the 1–fibular tunnel approach should be considered a viable option for the surgical therapy of chronic ankle instability. Clinical randomized prospective trials are needed to determine the clinical outcome of the 1-tunnel approach.

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Ankle Stability in Simulated Lateral Ankle Ligament Injuries

Foot & Ankle International ◽

10.3113/fai.2010.0531 ◽

2010 ◽

Vol 31 (6) ◽

pp. 531-537 ◽

Cited By ~ 11

Author(s):

Tadashi Fujii ◽

Harold B. Kitaoka ◽

Kota Watanabe ◽

Zong-Ping Luo ◽

Kai-Nan An

Keyword(s):

Ligament Injuries ◽

Lateral Ankle ◽

Ankle Stability ◽

Ankle Ligament ◽

Lateral Ankle Ligament

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Early versus Delayed Mobilization Post-Operative Protocols for Primary Lateral Ankle Ligament Repair: A Systematic Review and Meta-analysis

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00077 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0007

Author(s):

Matthew L. Vopat ◽

Armin Tarakemeh ◽

Brandon Morris ◽

Maaz Hassan ◽

Pat Garvin ◽

...

Keyword(s):

Ankle Instability ◽

Meta Analysis ◽

Return To Sport ◽

Early Mobilization ◽

Lateral Ligament ◽

Ligament Repair ◽

Lateral Ankle ◽

Ankle Ligament ◽

Lateral Ankle Ligament ◽

Primary Lateral

Category: Ankle, Sports, Post-op protocol Introduction/Purpose: Lateral ankle instability represents a common orthopaedic diagnosis. Nonoperative treatment through focused physical therapy provides satisfactory results in most patients. Some patients, however, experience persistent chronic lateral ankle instability despite appropriate nonoperative treatment. These patients may require stabilization which can include primary lateral ligament repair to restore ankle stability. Optimal post-operative rehabilitation of lateral ankle ligament repairs remains unknown, as surgeon vary in how they balance protection of surgical repair with immobilization with the need for ankle joint mobilization to restore range of motion. The aim of this review is to provide insight into early and delayed mobilization post- operative protocols in patients undergoing primary lateral ankle ligament repairs to determine if an optimal evidence-based post- operative rehabilitation protocol exists in the literature. Methods: Following PRIMSA criteria, a meta-analysis using the PubMed/Ovid Medline database was performed (10/11/1947- 10/16/2017). Manuscripts that were duplicates, non-lateral ligament repair, biomechanical and non-English language were excluded. Protocols were reviewed and divided into two categories; early mobilization (within 3 weeks of surgery) and delayed mobilization (after 4 weeks of surgery). Return to sport, outcome scores (AOFAS, Karlsson scores) and complications of both populations were recorded and statistically analyzed. Results: 31 out of 1,844 studies met the criteria for the final analysis, representing 1,608 patients undergoing primary lateral ligament repair. There was no statistical difference in pre-operative AOFAS scores with delayed mobilization having a score of 67.3 and early mobilization having a score of 67.6 (p<0.639). There was statistical significance in the post-operative AOFAS score comparing delayed mobilization group versus early mobilization group with 91.8 versus 98.8, respectively (p<0.001) and post- operative Karlsson scores with values of 90.0 vs. 92.2 in delayed versus early respectively (p<0.001). Return to sport in the delayed group was 11.8 weeks versus 10.9 in early (p<0.044). No significant difference was found in complication rates between groups with delayed having a rate of 3.7% and early 4.8% (p<0.389). Conclusion: Patients may benefit from early mobilization protocols after lateral ankle ligament repair. The early mobilization protocols group had improved functional outcomes and decreased time until return to sport without a difference in complications. More studies are needed to definitively evaluate early versus delayed rehabilitation protocols due to heterogeneity of the studies.

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The Role of the Accessory Malleolar Ossicles and Malleolar Avulsion Fractures in Lateral Ankle Ligament Reconstruction

Foot & Ankle Specialist ◽

10.1177/1938640017729498 ◽

2017 ◽

Vol 11 (4) ◽

pp. 308-314 ◽

Cited By ~ 4

Author(s):

Matthew M. Reiner ◽

Jonathan J. Sharpe

Keyword(s):

Risk Factor ◽

Conservative Treatment ◽

The United States ◽

Ankle Sprains ◽

Ligament Repair ◽

Avulsion Fractures ◽

Lateral Ankle ◽

Accessory Ossicles ◽

Ankle Ligament ◽

Lateral Ankle Ligament

While it is well known that ankle sprains are one of the most common injuries in the United States, predictive factors regarding failure of conservative treatment are not well known. There are many biomechanical and epidemiological factors that play a role in recurrence and failure of conservative treatment, but most cases are able to be treated with immobilization and/or rest, ice, elevation, physical therapy, and bracing. We propose that one important risk factor is often overlooked simply due to the fact that a vast majority of these cases resolve without the need for surgery. Accessory ossicles and avulsion fractures of the malleoli or talus may represent a predisposition or marker for ligamentous damage that may lead to the need for lateral ankle ligament repair or reconstruction in the future. We have identified 61 consecutive patients who underwent lateral ankle ligament repair or reconstruction by the primary surgeon from the years 2007 to 2017. Out of those patients who met our inclusion and exclusion criteria, 66% had the presence of osseous pathology consisting of accessory ossicles or avulsion fractures of the medial or lateral malleolus or talus. The proportion of osseous pathology seen with lateral ankle ligament repair or reconstruction was higher than what has been previously reported in both operative and nonoperative settings. This may help identify a risk factor for failure of conservative treatment in patients presenting with acute ankle sprains or ankle instability especially in the active cohort. Levels of Evidence: Level IV: Case series

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