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Improved Outcome and Earlier Return to Activity After Suture Tape Augmentation Versus Broström Repair for Chronic Lateral Ankle Instability? A Systematic Review

Open AccessPublished:July 08, 2021DOI:https://doi.org/10.1016/j.arthro.2021.06.028

      Purpose

      To determine whether the use of suture tape augmentation (ST) would lead to improved clinical outcomes, increased stability, shorter postoperative immobilization, and earlier return to activity and sports compared with Broström repair (BR) in surgical treatment of chronic lateral ankle instability (CLAI).

      Methods

      A systematic literature search was performed using Pubmed and Embase according to PRISMA guidelines. The following search terms were used: ankle instability, suture tape, fiber tape, and internal brace. Full-text articles in English that directly compared BR and ST cohorts were included, with a minimum cohort size of 40 patients. Exclusion criteria were former systematic reviews, biomechanical studies, and case reports.

      Results

      Ultimately, 7 clinical trials were included in this systematic review. Regarding the clinical and radiologic outcomes and complication rates, no major differences were detected between groups. Recurrence of instability and revision surgeries tended to occur more often after BR, whereas irritation of the peroneal nerve and tendons seemed to occur more frequently after ST. Postoperative rehabilitation protocols were either the same for both groups or more aggressive in the ST groups. When both techniques were performed with arthroscopic assistance, return to sports was significantly faster in the ST groups.

      Conclusions

      In conclusion, suture tape augmentation showed excellent results and is a safe technique comparable to traditional Broström repair. No major differences regarding clinical and radiologic outcomes or complications were found.

      Level of Evidence

      III, systematic review of level I, II, and III studies.
      Lateral ankle sprains are among the most common sports injuries.
      • Guillo S.
      • Bauer T.
      • Lee J.W.
      • et al.
      Consensus in chronic ankle instability: Aetiology, assessment, surgical indications and place for arthroscopy.
      ,
      • Ferran N.A.
      • Oliva F.
      • Maffulli N.
      Ankle instability.
      Initial conservative therapy offers a good chance to regain ankle stability, but many ankle sprains and thus lateral ligament injuries remain untreated.
      • Al-Mohrej O.A.
      • Al-Kenani N.S.
      Acute ankle sprain: Conservative or surgical approach?.
      Consequently, about 10% to 20% of patients develop chronic lateral ankle instability (CLAI).
      • De Vries J.S.
      • Krips R.
      • Sierevelt I.N.
      • Blankevoort L.
      • van Dijk C.N.
      Interventions for treating chronic ankle instability.
      ,
      • Gould N.
      • Seligson D.
      • Gassman J.
      Early and late repair of lateral ligament of the ankle.
      About half of these patients eventually need surgery in spite of extensive proprioceptive training.
      • Viens N.A.
      • Wijdicks C.A.
      • Campbell K.J.
      • Laprade R.F.
      • Clanton T.O.
      Anterior talofibular ligament ruptures, part 1: Biomechanical comparison of augmented Broström repair techniques with the intact anterior talofibular ligament.
      The Broström technique and its modifications are currently the gold standard in surgical treatment of CLAI.
      • Cottom J.M.
      • Rigby R.B.
      The all inside arthroscopic Broström procedure: A prospective study of 40 consecutive patients.
      First described in 1966, Broström repair (BR) comprises direct suture repair of the pulled ends of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). The Broström-Gould modification includes use of the extensor retinaculum to augment the ligament repair.
      • Broström L.
      Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures.
      ,
      • Hamilton W.G.
      • Thompson F.M.
      • Snow S.W.
      The modified Brostrom procedure for lateral ankle instability.
      In recent modifications, ≥1 suture anchors are used to reattach the ligament remnants as well as the extensor retinaculum to their original footprint at the tip of the lateral malleolus.
      • Cho B.K.
      • Kim Y.M.
      • Kim D.S.
      • Choi E.S.
      • Shon H.C.
      • Park K.J.
      Outcomes of the modified Brostrom procedure using suture anchors for chronic lateral ankle instability—A prospective, randomized comparison between single and double suture anchors.
      Nonetheless, the Broström procedure and any of its modifications rely on postoperative protocols with limited weightbearing and ankle immobilization to avoid ligament lengthening because of its dependence on maturation of the native tissue.
      • Akeson W.H.
      • Amiel D.
      • Abel M.F.
      • Garfin S.R.
      • Woo S.L.
      Effects of immobilization on joints.
      ,
      • Provenzano P.P.
      • Martinez D.A.
      • Grindeland R.E.
      • et al.
      Hindlimb unloading alters ligament healing.
      Biomechanical studies have shown that reconstruction of the ATFL does not achieve the strength of the native ligament, even with suture anchor repair. Thus, aggressive postoperative rehabilitation protocols should be avoided.
      • Waldrop 3rd, N.E.
      • Wijdicks C.A.
      • Jansson K.S.
      • LaPrade R.F.
      • Clanton T.O.
      Anatomic suture anchor versus the Broström technique for anterior talofibular ligament repair: a biomechanical comparison.
      ,
      • Kirk K.L.
      • Campbell J.T.
      • Guyton G.P.
      • Parks B.G.
      • Schon L.C.
      ATFL elongation after Brostrom procedure: a biomechanical investigation.
      Suture tape augmentation (ST), or “internal bracing,” is performed by using ultra-high molecular weight polyethylene/polyester tapes and knotless bone anchors that are supposed to contribute to scar tissue formation, restore ankle stability, and hence protect the repaired ligament during healing.
      • Boey H.
      • Verfaillie S.
      • Natsakis T.
      • Sloten J.V.
      • Jonkers I.
      Augmented ligament reconstruction partially restores hindfoot and midfoot kinematics after lateral ligament ruptures.
      • Lohrer H.
      • Bonsignore G.
      • Dorn-Lange N.
      • Li L.
      • Gollhofer A.
      • Gehring D.
      Stabilizing lateral ankle instability by suture tape—A cadaver study.
      • Willegger M.
      • Benca E.
      • Hirtler L.
      • et al.
      Biomechanical stability of tape augmentation for anterior talofibular ligament (ATFL) repair compared to the native ATFL.
      • 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.
      • Vega J.
      • Montesinos E.
      • Malagelada F.
      • Baduell A.
      • Guelfi M.
      • Dalmau-Pastor M.
      Arthroscopic all-inside anterior talo-fibular ligament repair with suture augmentation gives excellent results in case of poor ligament tissue remnant quality.
      The aim of this study was to determine whether the use of ST would lead to improved clinical outcomes, increased stability, shorter postoperative immobilization, and earlier return to activity and sports compared with BR in surgical treatment of CLAI. The authors hypothesized that patients treated with suture tape augmentation would experience improved outcomes and fewer complications, would receive intensified postoperative rehabilitation protocols, and would experience earlier return to activity.

      Methods

      A systematic literature review was performed using Pubmed and Embase in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines.
      • Moher D.
      • Shamseer L.
      • Clarke M.
      • et al.
      Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement.
      The final search date was February 6, 2021. The search was not restricted by year of publication. The following search algorithm was used: “ankle instability” AND (“suture tape” OR “fiber tape” OR “internal brace”). Articles with levels I, II, and III evidence in the English language were considered. Not only studies in print journals, but also electronically published articles and conference records were eligible for analysis and investigation. All references within the included articles were manually cross-checked to supplement the electronic searches and identify any additional potentially relevant studies. If there was any disagreement on study choice, the subject was discussed between the first and senior author until agreement was achieved. Specific inclusion and exclusion criteria were applied to identify trials that contained information on preoperative conditions as well as postoperative clinical outcomes, postoperative rehabilitation, and return to sports. As ST is a relatively novel approach and literature on this topic, especially in comparison to BR, is still rare, nonrandomized cohort studies as well as randomized trials were included.
      To quantify the risk of selection bias and potential confounding associated with nonrandomized trials, the Methodological Index for Non-randomized Studies (MINORS) was calculated for all those trials as summarized in Table 1, with a global ideal score of 24 for comparative studies.
      • Slim K.
      • Nini E.
      • Forestier D.
      • Kwiatkowski F.
      • Panis Y.
      • Chipponi J.
      Methodological Index for Non-randomized Studies (MINORS): Development and validation of a new instrument.
      Risk of bias assessment for randomized controlled trials (RCTs) was performed by using the Cochrane Risk of Bias Assessment Tool, as demonstrated in Table 2.
      • Higgins J.P.
      • Altman D.G.
      • Gotzsche P.C.
      • et al.
      Cochrane Bias Methods Group; Cochrane Statistical Methods Group: The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.
      Inclusion criteria were (1) clinical trials directly comparing ST with BR in the treatment of chronic ankle instability, (2) English language, (3) full text provided, and (4) a minimum cohort size of 40 patients. Exclusion criteria comprised (1) former systematic reviews, (2) cadaveric or biomechanical studies, and (3) case reports.
      Table 1Overview of included studies
      PublicationStudy DesignLOEMINORS ScoreNumber of PatientsAge (y)Sex (M/F)Follow-Up (mo)
      Kulwin et al.
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      (2021)
      RCT2BR: 59;

      ST: 60
      BR: 41.4 (14.0);

      ST: 36.3 (15.5)
      BR: 13/46;

      ST: 27/32
      NA
      Ulku et al.
      • Ulku T.K.
      • Kocaoglu B.
      • Tok O.
      • Irgit K.
      • Nalbantoglu U.
      Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.
      (2019)
      RCT2BR: 31;

      ST: 30
      BR: 28.6 (19 to 44);

      ST: 27.8 (27 to 58)
      NABR: 36.8 (27 to 58);

      ST: 35.9 (26 to 54)
      Porter et al.
      • Porter M.
      • Shadbolt B.
      • Ye X.
      • Stuart R.
      Ankle lateral ligament augmentation versus the modified Broström-Gould procedure. A 5-year randomized controlled trial.
      (2019)
      RCT1BR: 25;

      ST: 22
      BR: 24.0 (6.9);

      ST: 26.1 (8.3)
      BR: 13/12;

      ST: 12/10
      NA
      Cho et al.
      • Cho B.K.
      • Park J.K.
      • Choi S.M.
      • SooHoo N.F.
      A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability.
      (2019)
      RCT2BR: 27;

      ST: 28
      BR: 28.1 (17 to 39);

      ST: 26.6 (16 to 40)
      BR: 0/27;

      ST: 0/28
      BR: 33.8 (24 to 44);

      ST: 34.6 (24 to 45)
      Xu et al.
      • Xu D.L.
      • Gan K.F.
      • Li H.J.
      • et al.
      Modified Broström repair with and without augmentation using suture tape for chronic lateral ankle instability.
      (2019)
      RCS118BR: 28;

      ST: 25
      BR: 28.1 (19.4, 17 to 55);

      ST: 26.6 (17.8, 16 to 50)
      NABR: 24;

      ST: 24
      Devries et al.
      • DeVries J.G.
      • Scharer B.M.
      • Romdenne T.A.
      Ankle stabilization with arthroscopic versus open with suture tape augmentation techniques.
      (2019)
      RCS318BR: 43;

      ST: 12
      BR: 44.7 (13.2, 16 to 69);

      ST: 39.5 (16.0, 17 to 64)
      BR: 16/27;

      ST: 6/6
      BR: 24.2 (7.7);

      ST: 21.0 (7.1)
      Yoo et al.
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      (2016)
      RCS317BR: 63;

      ST: 22
      BR & ST: 23 (19 to 44)BR: 63/0;

      ST: 22/0
      BR: 7.4 (6 to 9);

      ST: 7.4 (6 to 9)
      Data are mean (range) or mean (SD, range).
      Abbreviations: BR, Broström repair; LOE, level of evidence; MINORS, Methodological Index for Non-randomized Studies; NA, not applicable; RCS, retrospective cohort study; RCT, randomized controlled trial; SD, standard deviation; ST, suture tape augmentation.
      Table 2Risk of bias assessment via the Cochrane Risk of Bias Assessment Tool for randomized controlled trials
      PublicationSelection BiasPerformance BiasDetection BiasAttrition BiasReporting BiasOther Bias
      Kulwin et al.
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      (2021)
      LUUHLH
      Ulku et al.
      • Ulku T.K.
      • Kocaoglu B.
      • Tok O.
      • Irgit K.
      • Nalbantoglu U.
      Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.
      (2019)
      LUULLU
      Porter et al.
      • Porter M.
      • Shadbolt B.
      • Ye X.
      • Stuart R.
      Ankle lateral ligament augmentation versus the modified Broström-Gould procedure. A 5-year randomized controlled trial.
      (2019)
      LHHLLU
      Cho et al.
      • Cho B.K.
      • Park J.K.
      • Choi S.M.
      • SooHoo N.F.
      A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability.
      (2019)
      LUULHU
      Abbreviations: H, high risk of bias; L, low risk of bias; U, uncertain risk of bias.
      The primary literature research was performed by the first author of the study, including study selection according to the PRISMA guidelines. Those articles finally eligible for the study were reviewed by both the first and senior authors.

      Statistical Analysis

      Statistical analysis was performed using Review Manager version 5.4 software (The Cochrane Collaboration). To quantify heterogeneity between studies, the I2 statistic was conducted, and forest plots were used for graphical representation.
      • Higgins J.P.
      • Thompson S.G.
      • Deeks J.J.
      • Altman D.G.
      Measuring inconsistency in meta-analyses.
      Low heterogeneity was indicated by an I2 value of <25%, and high heterogeneity was indicated by an I2 value of >75%. If the I2 value was >50%, a random-effects model was used; otherwise, a fixed-effects model was used. A descriptive summary of the demographic data of the respective patient cohorts was depicted as frequency (absolute numbers and percentage) for qualitative variables and mean, standard deviation (SD), and range for quantitative variables.

      Results

      The initial literature search using the above mentioned search terms revealed 62 studies, as depicted in Fig. 1. Two additional records were identified through cross-reference checking. After removal of 26 duplicates, articles were screened using the predefined inclusion and exclusion criteria, leaving 21 articles eligible. After review of the full text, 14 articles were excluded because they were not in the scope of this study. Ultimately, 7 clinical trials were included in this systematic review. From all 7 articles finally eligible for this study, full-text articles were either downloaded from the respective journal’s website or requested via the author’s own online library.
      Figure thumbnail gr1
      Fig 1PRISMA flow diagram of the identification of relevant studies.
      Of the included studies, 4 were RCTs and 3 were retrospective cohort studies. Table 1 summarizes the study characteristics and risk of bias assessment for nonrandomized studies according to the MINORS index, and Table 2 includes bias assessment for RCTs according to the Cochrane Risk of Bias Assessment tool.
      Table 3 summarizes the clinical outcomes measured by different scores, including Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM), Foot and Ankle Disability Index (FADI), and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS). Moreover, radiologic outcomes including talar tilt angle (TTA) and anterior talar translation (ATT) are reported in Table 3.
      Table 3Evaluation of clinical and radiologic outcomes (mean ± SD)∗
      PublicationFAOSFAAM, ADLFAAM, Sports ActivityFAAM, TotalAOFASTTA (°)ATT (mm)
      Kulwin et al.
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      (2021)
      NANANANANANANA
      Ulku et al.
      • Ulku T.K.
      • Kocaoglu B.
      • Tok O.
      • Irgit K.
      • Nalbantoglu U.
      Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.
      (2019)
      BR: 90.6 ± 5.2;

      ST: 91.5 ± 7.7
      BR: 93.7 ± 16;

      ST: 95.6 ± 14
      BR: 84.9 ± 14;

      ST: 90.4 ± 12
      BR: 89.3 ± 15;

      ST: 93 ± 13
      NABR: 4.7 ± 4.8;

      ST: 4.5 ± 4.4
      BR: 4.6 ± 4.1;

      ST: 4.3 ± 4.5
      Porter et al.
      • Porter M.
      • Shadbolt B.
      • Ye X.
      • Stuart R.
      Ankle lateral ligament augmentation versus the modified Broström-Gould procedure. A 5-year randomized controlled trial.
      (2019)
      BR: 75.1 ± 5.5;

      ST: 93.7 ± 6.0
      NANANANANANA
      Cho et al.
      • Cho B.K.
      • Park J.K.
      • Choi S.M.
      • SooHoo N.F.
      A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability.
      (2019)
      BR: 93.3 ± 6.1;

      ST: 91.9 ± 6.7
      BR: 95.2 ± 4.1;

      ST: 94.1 ± 4.9
      BR: 89.1 ± 8.8;

      ST: 84.6 ± 9.8
      BR: 92.2 ± 6.5;

      ST: 89.4 ± 7.4
      NABR: 3.9 ± 2.3;

      ST: 4.6 ± 2.6
      BR: 4.2 ± 2.1;

      ST: 4.5 ± 2.3
      Xu et al.
      • Xu D.L.
      • Gan K.F.
      • Li H.J.
      • et al.
      Modified Broström repair with and without augmentation using suture tape for chronic lateral ankle instability.
      (2019)
      NABR: 95.2 ± 5.0;

      ST: 95.3 ± 1.9
      BR: 78.2 ± 12.0;

      ST: 87.1 ± 5.4
      BR: 90.5 ± 5.1;

      ST: 93.1 ± 2.3
      BR: 96.3 ± 6.0;

      ST: 97.5 ± 3.3
      BR: 2.7 ± 1.4;

      ST: 2.4 ± 1.3
      BR: 3.1 ± 1.3;

      ST: 2.9 ± 1.6
      Devries et al.
      • DeVries J.G.
      • Scharer B.M.
      • Romdenne T.A.
      Ankle stabilization with arthroscopic versus open with suture tape augmentation techniques.
      (2019)
      NANANANANANANA
      Yoo et al.
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      (2016)
      NANANANABR: 98.0 ± 16.8;

      ST: 96.5 ± 5.4
      NANA
      Data are mean ± SD.
      Abbreviations: ADL, activities of daily living; AOFAS, American Orthopedic Foot and Ankle Society Score; ATT, anterior talar translation (mm); BR, Broström repair; FAAM, Foot and Ankle Ability Measure; FAOS, Foot and Ankle Outcome Score; NA, not applicable; SD, standard deviation; ST, suture tape augmentation; TTA, talar tilt angle.

      Clinical and Radiologic Outcome Scores

      Postoperative AOFAS scores were reported in 2 studies (Xu et al.
      • Xu D.L.
      • Gan K.F.
      • Li H.J.
      • et al.
      Modified Broström repair with and without augmentation using suture tape for chronic lateral ankle instability.
      and Yoo et al.
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      ). FAOS scores were reported in 3 studies (Ulku et al.,
      • Ulku T.K.
      • Kocaoglu B.
      • Tok O.
      • Irgit K.
      • Nalbantoglu U.
      Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.
      Porter et al.,
      • Porter M.
      • Shadbolt B.
      • Ye X.
      • Stuart R.
      Ankle lateral ligament augmentation versus the modified Broström-Gould procedure. A 5-year randomized controlled trial.
      and Cho et al.
      • Cho B.K.
      • Park J.K.
      • Choi S.M.
      • SooHoo N.F.
      A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability.
      ). The forest plot is depicted in Fig 2.
      Figure thumbnail gr2
      Fig 2Results of aggregate analysis for comparison of FAOS scores between Broström and suture tape augmentation groups. Abbreviations: FAOS, Foot and Ankle Outcome Score; IV, inverse variance.
      Total FAAM scores, FAAM sports activity scores, and FAAM activities of daily living (ADL) scores were reported in 3 studies (Ulku et al.,
      • Ulku T.K.
      • Kocaoglu B.
      • Tok O.
      • Irgit K.
      • Nalbantoglu U.
      Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.
      Cho et al.,
      • Cho B.K.
      • Park J.K.
      • Choi S.M.
      • SooHoo N.F.
      A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability.
      and Xu et al.
      • Xu D.L.
      • Gan K.F.
      • Li H.J.
      • et al.
      Modified Broström repair with and without augmentation using suture tape for chronic lateral ankle instability.
      ). The forest plots are presented in Fig 3, 4, and 5. TTA and ATT were examined in 3 studies (Ulku et al.,
      • Ulku T.K.
      • Kocaoglu B.
      • Tok O.
      • Irgit K.
      • Nalbantoglu U.
      Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.
      Cho et al.,
      • Cho B.K.
      • Park J.K.
      • Choi S.M.
      • SooHoo N.F.
      A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability.
      and Xu et al.
      • Xu D.L.
      • Gan K.F.
      • Li H.J.
      • et al.
      Modified Broström repair with and without augmentation using suture tape for chronic lateral ankle instability.
      ). The forest plots are depicted in Fig 6 and 7.
      Figure thumbnail gr3
      Fig 3Results of aggregate analysis for comparison of total FAAM scores between Broström and suture tape augmentation groups. Abbreviations: FAAM, Foot and Ankle Ability Measure; IV, inverse variance.
      Figure thumbnail gr4
      Fig 4Results of aggregate analysis for comparison of FAAM sports activity scores between Broström and suture tape augmentation groups. Abbreviations: FAAM, Foot and Ankle Ability Measure; IV, inverse variance.
      Figure thumbnail gr5
      Fig 5Results of aggregate analysis for comparison of FAAM ADL scores between Broström and suture tape augmentation groups. Abbreviations: ADL, activities of daily living; FAAM, Foot and Ankle Ability Measure; IV, inverse variance.
      Figure thumbnail gr6
      Fig 6Results of aggregate analysis for comparison of TTA scores between Broström and suture tape augmentation groups. Abbreviations: IV, inverse variance; TTA, talar tilt angle.
      Figure thumbnail gr7
      Fig 7Results of aggregate analysis for comparison of ATT scores between Broström and suture tape augmentation groups. Abbreviations: ATT, anterior talar translation; IV, inverse variance.

      Postoperative Treatment and Return to Activity

      An overview of postoperative treatment protocols and return to sports is given in Table 4. Both Ulku et al.
      • Ulku T.K.
      • Kocaoglu B.
      • Tok O.
      • Irgit K.
      • Nalbantoglu U.
      Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.
      and Yoo et al.
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      used a more cautious approach for patients treated with modified BR and instructed immobilization in a cast for 4 weeks. In the study by Yoo et al.,
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      nonweightbearing mobilization in the cast was performed for 2 weeks, whereas it was obligatory for 4 weeks in the study by Ulku et al.
      • Ulku T.K.
      • Kocaoglu B.
      • Tok O.
      • Irgit K.
      • Nalbantoglu U.
      Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.
      This was followed by partial and progressive weightbearing for 2 weeks and full weightbearing after 4 (Yoo et al.
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      ) and 6 (Ulku et al.
      • Ulku T.K.
      • Kocaoglu B.
      • Tok O.
      • Irgit K.
      • Nalbantoglu U.
      Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.
      ) weeks. The cast was replaced by a semirigid brace after 4 weeks in the study by Yoo et al.,
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      whereas no further device for stabilization after removal of the cast was imposed by Ulku et al.
      • Ulku T.K.
      • Kocaoglu B.
      • Tok O.
      • Irgit K.
      • Nalbantoglu U.
      Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.
      In the ST group, treatment protocols were similar in the studies by Ulku et al.
      • Ulku T.K.
      • Kocaoglu B.
      • Tok O.
      • Irgit K.
      • Nalbantoglu U.
      Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.
      and Yoo et al.
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      Even right after surgery, no cast was obligatory. Partial weightbearing was allowed for 2 weeks with an elastic ankle brace, followed by full weightbearing 2 weeks after surgery.
      Table 4Evaluation of postoperative treatment and rehabilitation protocols
      PublicationPostoperative MobilizationReturn to Preoperative Level of Activity
      Kulwin et al.
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      (2021)
      BR & ST: accelerated rehabilitation protocol as described by Coetzee et al. (2018),
      • Coetzee J.C.
      • Ellington J.K.
      • Ronan J.A.
      • Stone R.M.
      Functional results of open Broström ankle ligament repair augmented with a suture tape.
      short leg cast with crutches, WBAT, FWB as soon as patient comfortable; after 2 wk: cast removed, short-leg walking boot, again WBAT to FWB; after 4 wk: laced-up ankle brace for first 12 wk after surgery
      BR: 17.5 ± 5.1 wk;

      ST: 13.3 ± 5.2 wk;

      P = .00005
      Ulku et al.
      • Ulku T.K.
      • Kocaoglu B.
      • Tok O.
      • Irgit K.
      • Nalbantoglu U.
      Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.
      (2019)
      BR: below-knee cast for 4 wk with crutches, nonweightbearing; partial weightbearing for 2 wk; full weightbearing after 6 wk;

      ST: no cast, partial weightbearing with elastic ankle brace and crutches; full weightbearing 2 wk after surgery
      NA
      Porter et al.
      • Porter M.
      • Shadbolt B.
      • Ye X.
      • Stuart R.
      Ankle lateral ligament augmentation versus the modified Broström-Gould procedure. A 5-year randomized controlled trial.
      (2019)
      BR & ST: backslab for 7 to 10 d, nonweightbearing; WBAT in a brace until 6 wk after surgery; weaning off the brace, proprioceptive training; running allowed after 6 wkBR & ST: running allowed after 6 wk
      Cho et al.
      • Cho B.K.
      • Park J.K.
      • Choi S.M.
      • SooHoo N.F.
      A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability.
      (2019)
      BR & ST: nonweightbearing in a short leg cast for 3 wk; partial weightbearing in elastic ankle bandage for 2 wk; full weightbearing and proprioception training after 5 wk
      Xu et al.
      • Xu D.L.
      • Gan K.F.
      • Li H.J.
      • et al.
      Modified Broström repair with and without augmentation using suture tape for chronic lateral ankle instability.
      (2019)
      NANA
      Devries et al.
      • DeVries J.G.
      • Scharer B.M.
      • Romdenne T.A.
      Ankle stabilization with arthroscopic versus open with suture tape augmentation techniques.
      (2019)
      BR & ST: nonweightbearing in a splint for 2 wk;

      BR: time to weightbearing in a boot: 21.5 ± 7.6 d, time to weightbearing in a brace: 41.8 ± 7.6 d;

      ST: time to weightbearing in a boot: 20.3 ± 9.4 d, time to weightbearing in a brace: 45.2 ± 7.8 d
      BR: 127.2 ± 96.3 d after surgery (range 53 to 569 d);

      ST: 170.7 ± 66.4 d after surgery (range 56 to 174);

      P = .008
      Yoo et al.
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      (2016)
      BR: short leg cast for 2 wk nonweightbearing; after 2 wk: progressive weightbearing; at 4 wk: cast removed, semirigid brace; at 6 wk: physical therapy started;

      ST: no cast, compression bandage without splint, progressive weightbearing; at 2 wk: physical therapy started
      BR: running and high-contact sports (soccer, basketball) allowed 12 wk after surgery, after 12 wk: 27.0% returned to sports;

      ST: running and high-contact sports (soccer, basketball) allowed after 4 wk, after 12 wk: 81.8% returned to sports;

      P < .001
      Data are mean ± SD.
      Abbreviations: BR, Broström repair; FWB, full weightbearing; NA, not applicable; SD, standard deviation; ST, suture tape augmentation; WBAT, weightbearing as tolerated.
      Porter et al.
      • Porter M.
      • Shadbolt B.
      • Ye X.
      • Stuart R.
      Ankle lateral ligament augmentation versus the modified Broström-Gould procedure. A 5-year randomized controlled trial.
      and Cho et al.
      • Cho B.K.
      • Park J.K.
      • Choi S.M.
      • SooHoo N.F.
      A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability.
      had no difference between patient groups regarding postoperative rehabilitation protocols. Porter et al.
      • Porter M.
      • Shadbolt B.
      • Ye X.
      • Stuart R.
      Ankle lateral ligament augmentation versus the modified Broström-Gould procedure. A 5-year randomized controlled trial.
      prescribed a backslab for 7 to 10 days, nonweightbearing, followed by weightbearing as tolerated (WBAT) in a brace until 6 weeks postoperatively. Running was allowed for both BR and ST patient groups after 6 weeks. Cho et al.
      • Cho B.K.
      • Park J.K.
      • Choi S.M.
      • SooHoo N.F.
      A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability.
      applied nonweightbearing in a short leg cast for 3 weeks, followed by partial weightbearing in an elastic ankle bandage for another 2 weeks. After 5 weeks, full weightbearing was allowed.
      In the study by DeVries et al.,
      • DeVries J.G.
      • Scharer B.M.
      • Romdenne T.A.
      Ankle stabilization with arthroscopic versus open with suture tape augmentation techniques.
      arthroscopic modified BR and open ST repair were compared. Postoperative mobilization was quite similar, with mean time to weightbearing in a boot for 20.3 ± 9.4 days (mean ± SD) in the open repair group and 21.5 ± 7.6 days in the arthroscopic repair group. Time to weightbearing in a brace was slightly longer in the open repair group, amounting to 45.2 ± 7.8 days, compared with 41.8 ± 7.6 days in the arthroscopic group.
      In the trial by Kulwin et al.,
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      an accelerated rehabilitation protocol previously described by Coetzee et al.
      • Coetzee J.C.
      • Ellington J.K.
      • Ronan J.A.
      • Stone R.M.
      Functional results of open Broström ankle ligament repair augmented with a suture tape.
      was followed for both BR and ST patient groups. Patients wore a short-leg cast for 2 weeks after surgery but were told to perform full weightbearing as soon as they were comfortable. After 2 weeks, the cast was removed and replaced with a short-leg walking boot. After 4 weeks, a laced-up ankle brace was applied and had to be worn for another 8 weeks.
      Return to preoperative level of activity was reported in 3 studies (DeVries et al.,
      • DeVries J.G.
      • Scharer B.M.
      • Romdenne T.A.
      Ankle stabilization with arthroscopic versus open with suture tape augmentation techniques.
      Kulwin et al.,
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      and Yoo et al.
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      ), presenting quite different results. In the study by Kulwin et al.,
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      return to activity was significantly faster (P = .00005) in the ST group (13.3 ± 5.2 weeks) than in the BR group (17.5 ± 5.1 weeks). In contrast, DeVries et al.
      • DeVries J.G.
      • Scharer B.M.
      • Romdenne T.A.
      Ankle stabilization with arthroscopic versus open with suture tape augmentation techniques.
      reported a significantly faster return to preoperative activity after modified BR at 127.2 ± 96.3 days compared with 170.7 ± 66.4 days after ST (P = .008). Kulwin et al.
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      performed ST with arthroscopic assistance, whereas DeVries et al.
      • DeVries J.G.
      • Scharer B.M.
      • Romdenne T.A.
      Ankle stabilization with arthroscopic versus open with suture tape augmentation techniques.
      used an open approach for ST, but an all-arthroscopic approach for modified BR. Yoo et al.
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      differentiated return to sports between modified BR and ST. Patients in the BR group were permitted to return to running and high-contact sports, such as soccer and basketball, after 12 weeks, whereas patients in the ST group were allowed to do so after 4 weeks. Ultimately, the study showed that after 12 weeks, 81.8% of patients from the ST group were actually able to return to sports, whereas the proportion in the BR group was only 27.0% (P < .001).
      In summary, 4 studies applied the same rehabilitation protocols to the patients who received modified BR and those who received ST. Kulwin et al.
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      and Porter et al.
      • Porter M.
      • Shadbolt B.
      • Ye X.
      • Stuart R.
      Ankle lateral ligament augmentation versus the modified Broström-Gould procedure. A 5-year randomized controlled trial.
      used an accelerated rehabilitation approach and allowed WBAT right after surgery
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      or after 7 to 10 days.
      • Porter M.
      • Shadbolt B.
      • Ye X.
      • Stuart R.
      Ankle lateral ligament augmentation versus the modified Broström-Gould procedure. A 5-year randomized controlled trial.
      Still, Kulwin et al.
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      proved that with the same rehabilitation approach, return to the preoperative level of activity was significantly faster after ST. Cho et al.
      • Cho B.K.
      • Park J.K.
      • Choi S.M.
      • SooHoo N.F.
      A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability.
      and DeVries et al.
      • DeVries J.G.
      • Scharer B.M.
      • Romdenne T.A.
      Ankle stabilization with arthroscopic versus open with suture tape augmentation techniques.
      applied a more cautious protocol to both groups, with nonweightbearing for 2 weeks
      • DeVries J.G.
      • Scharer B.M.
      • Romdenne T.A.
      Ankle stabilization with arthroscopic versus open with suture tape augmentation techniques.
      and 3 weeks.
      • Cho B.K.
      • Park J.K.
      • Choi S.M.
      • SooHoo N.F.
      A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability.
      In the 2 studies that used different rehabilitation protocols for BR and ST groups, mobilization after ST took place without a cast and with partial (Ulku et al.
      • Ulku T.K.
      • Kocaoglu B.
      • Tok O.
      • Irgit K.
      • Nalbantoglu U.
      Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.
      ) and progressive (Yoo et al.
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      ) weightbearing right after surgery.

      Complication Rates

      Complication rates, especially concerning wound infection, irritation of the peroneal nerve and tendons, recurrent instability, and the need for revision surgery, were reported in all included trials. An overview is given in Table 5, and the concomitant forest plots are depicted in Fig 8, Fig 9, Fig 10, Fig 11, Fig 12. Recurrence of instability and revision surgeries tended to occur more often after BR, whereas irritation of the peroneal nerve and tendons seemed to occur more frequently after suture tape augmentation. Overall complication rate and the risk for wound infection tended to be slightly higher after BR.
      • Xu D.L.
      • Gan K.F.
      • Li H.J.
      • et al.
      Modified Broström repair with and without augmentation using suture tape for chronic lateral ankle instability.
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      • Ulku T.K.
      • Kocaoglu B.
      • Tok O.
      • Irgit K.
      • Nalbantoglu U.
      Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.
      • Porter M.
      • Shadbolt B.
      • Ye X.
      • Stuart R.
      Ankle lateral ligament augmentation versus the modified Broström-Gould procedure. A 5-year randomized controlled trial.
      • Cho B.K.
      • Park J.K.
      • Choi S.M.
      • SooHoo N.F.
      A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability.
      • DeVries J.G.
      • Scharer B.M.
      • Romdenne T.A.
      Ankle stabilization with arthroscopic versus open with suture tape augmentation techniques.
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      Table 5Complication rates
      PublicationComplication RateIrritation of Peroneal Nerve/TendonsWound InfectionRecurrent InstabilityRevision Surgery
      Kulwin et al.
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      (2021)
      BR: 8.3 (4/48);

      ST: 1.8 (1/56)
      BR: 0.0 (0/48);

      ST: 0.0 (0/56)
      BR: 2.1 (1/48);

      ST: 1.8 (1/56)
      BR: 4.2 (2/48);

      ST: 0.0 (0/56)
      BR: 4.2 (2/48);

      ST: 0.0 (0/56)
      Ulku et al.
      • Ulku T.K.
      • Kocaoglu B.
      • Tok O.
      • Irgit K.
      • Nalbantoglu U.
      Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.
      (2019)
      BR: 9.7 (3/31);

      ST: 3.3 (1/30)
      BR: 0.0 (0/31);

      ST: 0.0 (0/30)
      BR: 3.2 (1/31);

      ST: 0.0 (0/30)
      BR: 6.5 (2/31);

      ST: 3.3 (1/30)
      BR: 6.5 (2/31);

      ST: 3.3 (1/30)
      Porter et al.
      • Porter M.
      • Shadbolt B.
      • Ye X.
      • Stuart R.
      Ankle lateral ligament augmentation versus the modified Broström-Gould procedure. A 5-year randomized controlled trial.
      (2019)
      BR: 20.0 (5/25);

      ST: 13.6 (3/22)
      BR: 0.0 (0/25);

      ST: 4.5 (1/22)
      BR: 4.0 (1/25);

      ST: 9.1 (2/22)
      BR: 12.0 (3/25);

      ST: 0.0 (0/22)
      BR: 12.0 (3/25);

      ST: 9.1 (2/22)
      Cho et al.
      • Cho B.K.
      • Park J.K.
      • Choi S.M.
      • SooHoo N.F.
      A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability.
      (2019)
      BR: 11.1 (3/27);

      ST: 10.7 (3/28)
      BR: 3.7 (1/27);

      ST: 3.6 (1/28)
      BR: 3.7 (1/27);

      ST: 0.0 (0/28)
      BR: 3.7 (1/27);

      ST: 7.1 (2/28)
      BR: 0.0 (0/27);

      ST: 0.0 (0/28)
      Xu et al.
      • Xu D.L.
      • Gan K.F.
      • Li H.J.
      • et al.
      Modified Broström repair with and without augmentation using suture tape for chronic lateral ankle instability.
      (2019)
      BR: 7.1 (2/28);

      ST: 12.0 (3/25)
      BR: 0.0 (0/28);

      ST: 12.0 (3/25)
      BR: 3.6 (1/28);

      ST: 0.0 (0/25)
      BR: 3.6 (1/28);

      ST: 0.0 (0/25)
      BR: 3.6 (1/28);

      ST: 0.0 (0/25)
      Devries et al.
      • DeVries J.G.
      • Scharer B.M.
      • Romdenne T.A.
      Ankle stabilization with arthroscopic versus open with suture tape augmentation techniques.
      (2019)
      BR: 14.0 (6/43);

      ST: 16.7 (2/12)
      BR: 0.0 (0/43);

      ST: 8.3 (1/12)
      BR: 4.7 (2/43);

      ST: 8.3 (1/12)
      BR: 9.3 (4/43);

      ST: 0.0 (0/12)
      BR: 11.6 (5/43);

      ST: 0.0 (0/12)
      Yoo et al.
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      (2016)
      BR: 8.0 (5/63);

      ST: 9.0 (2/22)
      BR: 3.2 (2/63);

      ST: 0.0 (0/22)
      BR: 0.0 (0/63);

      ST: 0.0 (0/22)
      BR: 0.0 (0/63);

      ST: 0.0 (0/22)
      BR: 0.0 (0/63);

      ST: 0.0 (0/22)
      Data are % (proportion).
      Abbreviations: BR, Broström repair; ST, suture tape augmentation.
      Figure thumbnail gr8
      Fig 8Results of aggregate analysis for comparison of overall complication rates between Broström and suture tape augmentation groups. Numbers for “events” refer to failure; numbers for “total” refer to total participants. Abbreviations: M-H, Mantel-Haenszel method.
      Figure thumbnail gr9
      Fig 9Results of aggregate analysis for comparison of recurrence of instability rates between Broström and suture tape augmentation groups. Numbers for “events” refer to failure; numbers for “total” refer to total participants. Abbreviations: M-H, Mantel-Haenszel method.
      Figure thumbnail gr10
      Fig 10Results of aggregate analysis for comparison of wound infection rates between Broström and suture tape augmentation groups. Numbers for “events” refer to failure; numbers for “total” refer to total participants. Abbreviations: M-H, Mantel-Haenszel method.
      Figure thumbnail gr11
      Fig 11Results of aggregate analysis for comparison of rates for irritation of peroneal nerve and tendons between Broström and suture tape augmentation groups. Numbers for “events” refer to failure; numbers for “total” refer to total participants. Abbreviations: M-H, Mantel-Haenszel method.
      Figure thumbnail gr12
      Fig 12Results of aggregate analysis for comparison of revision surgery rates between Broström and suture tape augmentation groups. Numbers for “events” refer to failure; numbers for “total” refer to total participants. Abbreviations: M-H, Mantel-Haenszel method.

      Discussion

      One of the most important findings of this study was that clinical and radiologic outcomes did not differ considerably after treatment of CLAI with either modified Broström repair or suture tape augmentation. Concerning complications, recurrence of instability and revision surgeries tended to occur more often after BR, whereas irritation of the peroneal nerve and tendons seemed to occur more frequently after ST. This might be caused by injury to the superficial peroneal nerve and also irritation by suture knots or prominent anchors.
      • Corte-Real N.
      • Moreira R.
      Arthroscopic repair of chronic lateral ankle instability.
      ,
      • Kim E.S.
      • Lee K.T.
      • Parks J.S.
      • Lee Y.K.
      Arthroscopic anterior talofibular ligament repair for chronic ankle instability with a suture anchor technique.
      In this study, randomized trials as well as nonrandomized cohort studies were included, which might increase the risk for selection bias and confounding. Therefore, MINORS scores were calculated for all nonrandomized trials to assess risk of bias.
      • Slim K.
      • Nini E.
      • Forestier D.
      • Kwiatkowski F.
      • Panis Y.
      • Chipponi J.
      Methodological Index for Non-randomized Studies (MINORS): Development and validation of a new instrument.
      The 3 included nonrandomized studies have scores ranging from 17 to 18, indicating tolerable scores, although risk of bias is evidently present. Points were mainly lost owing to lack of prospective data collection, absence of prospective calculation of study size, and only partial equivalence of groups. In all 3 studies, data collection was conducted retrospectively, and no adjustment for confounding variables was performed. However, comparison groups were present in all 3 nonrandomized studies. Risk of bias assessment for randomized controlled trials (RCTs) was performed by using the Cochrane Risk of Bias Assessment tool.
      • Higgins J.P.
      • Altman D.G.
      • Gotzsche P.C.
      • et al.
      Cochrane Bias Methods Group; Cochrane Statistical Methods Group: The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.
      High risks of performance and detection bias in the study by Porter et al.
      • Porter M.
      • Shadbolt B.
      • Ye X.
      • Stuart R.
      Ankle lateral ligament augmentation versus the modified Broström-Gould procedure. A 5-year randomized controlled trial.
      were mainly caused by the inability to blind researchers and patients for the surgical procedure chosen owing to the use of different skin incisions. In the study by Kulwin et al.,
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      loss to follow-up was disproportionately higher in the BR group, causing a high risk of attrition bias. The study by Cho et al.
      • Cho B.K.
      • Park J.K.
      • Choi S.M.
      • SooHoo N.F.
      A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability.
      only included young female patients, causing a high risk of reporting bias.
      Concerning postoperative rehabilitation protocols, several studies used a more restrained approach after modified BR, whereas others applied the same accelerated rehabilitation protocols after both surgical procedures. In studies in which rehabilitation protocols differed, ST entailed earlier return to full weightbearing and shorter cast immobilization, or even no cast at all. One outstanding finding was a faster return to preoperative level of activity after modified BR compared with ST in the study by DeVries et al.
      • DeVries J.G.
      • Scharer B.M.
      • Romdenne T.A.
      Ankle stabilization with arthroscopic versus open with suture tape augmentation techniques.
      This result was contrary to the findings of Kulwin et al.
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      and Yoo et al.,
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      who found that return to activity was significantly faster after ST. This discrepancy might be because DeVries et al.
      • DeVries J.G.
      • Scharer B.M.
      • Romdenne T.A.
      Ankle stabilization with arthroscopic versus open with suture tape augmentation techniques.
      compared an all-arthroscopic modified BR with open ST, making comparison of these results difficult, whereas Kulwin et al.
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      and Yoo et al.
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      used arthroscopic approaches for both treatment groups. This may imply that arthroscopic ligament repair could also be one of the key variables to achieve accelerated rehabilitation compared with open surgical approaches. Moreover, Kulwin et al.
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      and Yoo et al.
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      actually performed both methods arthroscopically or with arthroscopic assistance and showed a significantly faster return to sports. Kulwin et al.
      • Kulwin R.
      • Watson T.S.
      • Rigby R.
      • Coetzee J.C.
      • Vora A.
      Traditional modified Broström vs suture tape ligament augmentation.
      reported a mean time to return to sports of 13.3 ± 5.2 weeks in the ST group versus 17.5 ± 5.1 weeks in the BR group. Yoo et al.
      • Yoo J.S.
      • Yang E.A.
      Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.
      stated that 81.8% of those treated with ST, but only 27.0% of those treated with modified BR, were able to return to sports 12 weeks after surgery. This might be explained by higher stability of the ankle and reduced ligament elongation. Biomechanical studies have reported that BR results in only 50% of strength of the native ATFL.
      • Waldrop 3rd, N.E.
      • Wijdicks C.A.
      • Jansson K.S.
      • LaPrade R.F.
      • Clanton T.O.
      Anatomic suture anchor versus the Broström technique for anterior talofibular ligament repair: a biomechanical comparison.
      ,
      • Kirk K.L.
      • Campbell J.T.
      • Guyton G.P.
      • Parks B.G.
      • Schon L.C.
      ATFL elongation after Brostrom procedure: a biomechanical investigation.
      During early mobilization after ligament reconstruction, elongation of ligaments is associated with ankle laxity and hence decreased stability.
      • Omar M.
      • Petri M.
      • Dratzidis A.
      • et al.
      Biomechanical comparison of fixation techniques for medial collateral ligament anatomical augmented repair.
      Thus, it was hypothesized that suture tape augmentation could improve ankle stability by increasing stability of the reconstructed ATFL and protecting the ligament.
      • Boey H.
      • Verfaillie S.
      • Natsakis T.
      • Sloten J.V.
      • Jonkers I.
      Augmented ligament reconstruction partially restores hindfoot and midfoot kinematics after lateral ligament ruptures.
      • Lohrer H.
      • Bonsignore G.
      • Dorn-Lange N.
      • Li L.
      • Gollhofer A.
      • Gehring D.
      Stabilizing lateral ankle instability by suture tape—A cadaver study.
      • Willegger M.
      • Benca E.
      • Hirtler L.
      • et al.
      Biomechanical stability of tape augmentation for anterior talofibular ligament (ATFL) repair compared to the native ATFL.
      • 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.
      • Vega J.
      • Montesinos E.
      • Malagelada F.
      • Baduell A.
      • Guelfi M.
      • Dalmau-Pastor M.
      Arthroscopic all-inside anterior talo-fibular ligament repair with suture augmentation gives excellent results in case of poor ligament tissue remnant quality.
      A cadaveric study by Viens et al.
      • Viens N.A.
      • Wijdicks C.A.
      • Campbell K.J.
      • Laprade R.F.
      • Clanton T.O.
      Anterior talofibular ligament ruptures, part 1: Biomechanical comparison of augmented Broström repair techniques with the intact anterior talofibular ligament.
      was able to demonstrate that strength and stiffness of the suture tape–augmented construct was not significantly different from the native ATFL.
      Another biomechanical study by Schuh et al.
      • Willegger M.
      • Benca E.
      • Hirtler L.
      • et al.
      Biomechanical stability of tape augmentation for anterior talofibular ligament (ATFL) repair compared to the native ATFL.
      compared traditional BR, BR with suture anchor, and ST, reporting a 95% higher torque at failure in the ST group compared with traditional BR and a 54% higher torque at failure compared with BR plus suture anchor. ATFL reconstruction failed at an angle of 24.0° in the BR group, 36.0° in the BR with suture anchor group, and 35.5° (P = .02) in the ST group. These fundamental biomechanical findings can also serve as an explanation of why earlier return to full weightbearing, removal of cast, and return to sports are possible after ST. Along with longer immobilization, collagen remodeling and cellular orientation are altered, leading to reduced ligament strength.
      • Ahtikoski A.M.
      • Koskinen S.O.
      • Virtanen P.
      • Kovanen V.
      • Takala T.E.
      Regulation of synthesis of fibrillar collagens in rat skeletal muscle during immobilization in shortened and lengthened positions.
      Consequently, for a select highly active patient population benefiting from early accelerated rehabilitation and a more stable construct, ST might be the appropriate choice of treatment. Therefore, especially for athletes, ST offers a chance of earlier return to activity and consequently faster return to sports combined with a smaller rate of recurrent instability and need for revision surgery.
      Two recent systematic reviews also aimed to answer whether clinical and radiological outcomes differed significantly between patients treated with modified BR and ST.
      • Lewis T.L.
      • Joseph A.
      • Patel A.
      • Ahluwalia R.
      • Ray R.
      Modified Broström repair with suture tape augmentation for lateral ankle instability: A systematic review.
      ,
      • Hong Li
      • Zhao Y.
      • Chen W.
      • Li Hongyun
      • Hua Y.
      No differences in clinical outcomes of suture tape augmented repair versus Broström repair surgery for chronic lateral ankle instability.
      Both studies confirmed that in terms of clinical and radiological outcome scores, no statistically significant difference between groups could be found. This agrees with our analysis. However, statistical analysis of complication rates was not performed in the systematic review by Lewis et al.
      • Lewis T.L.
      • Joseph A.
      • Patel A.
      • Ahluwalia R.
      • Ray R.
      Modified Broström repair with suture tape augmentation for lateral ankle instability: A systematic review.
      The study conducted by Li et al.
      • Hong Li
      • Zhao Y.
      • Chen W.
      • Li Hongyun
      • Hua Y.
      No differences in clinical outcomes of suture tape augmented repair versus Broström repair surgery for chronic lateral ankle instability.
      included testing for statistical significance concerning overall complication rates and the risk for recurrent instability and found no significant difference, which is confirmed by the results of this review.
      Another important factor is long-term stability of the suture tape construct. A study by Maffulli et al.
      • Maffulli N.
      • Del Buono A.
      • Maffulli G.D.
      • et al.
      Isolated anterior talofibular ligament Broström repair for chronic lateral ankle instability: 9-year follow-up.
      examining long-term follow-up of patients treated with traditional BR for CLAI reported poor outcomes for those suffering from ligamentous laxity before surgery. The study demonstrated that 26% of patients quit sports activity after BR, and another 16% reduced sports activity compared with preoperative terms. Because ST is still a relatively novel approach, long-term outcomes are not yet available, and the durability of ankle stabilization by suture taping needs to be confirmed. Moreover, long-term effects could not be compared between BR and ST methods yet, leaving the question if one method might be more capable to delay or even prevent the occurrence of premature osteoarthritis of the ankle joint, as several previous studies have reported the impact of ankle instability and treatment by ankle arthroscopy on the development of osteoarthritis.
      • Hirose K.
      • Murakami G.
      • Minowa T.
      • Kura H.
      • Yamashita T.
      Lateral ligament injury of the ankle and associated articular cartilage degeneration in the talocrural joint: Anatomic study using elderly cadavers.
      • Ferkel R.D.
      • Chams R.N.
      Chronic lateral instability: Arthroscopic findings and long-term results.
      • Takao M.
      • Uchio Y.
      • Naito K.
      • Fukazawa I.
      • Ochi M.
      Arthroscopic assessment for intra-articular disorders in residual ankle disability after sprain.
      Long-term randomized studies with larger patient cohorts and longer follow-up of both surgical methods will be necessary to confirm these results, especially regarding long-term stability and long-term effects on the development of osteoarthritis.

      Limitations

      There were several limitations to this systematic review. First, because of the novelty of suture tape augmentation in treatment of CLAI and hence the lack of studies comparing this method to Broström repair, randomized trials as well as nonrandomized cohort studies were included, which might increase the risk for selection bias and confounding. Thus, no statistical analysis of results was performed. Second, only 7 studies were included in total. Moreover, all studies showed a high heterogeneity. Altogether, more patients receiving modified BR (276 versus 199 in the ST group) were included in the selected studies. Furthermore, although 7 studies with an acceptable patient number were included altogether, not all mentioned clinical scores were evaluated in all of the studies, and as Table 3 shows, some were evaluated in only 2 or 3 studies. This low number of studies might cause difficulties in drawing valid conclusions. Moreover, return to sports was not calculated in all included studies.

      Conclusions

      In conclusion, suture tape augmentation showed excellent results and is a safe technique comparable to traditional Broström repair. No major differences regarding clinical and radiologic outcomes or complications were found.

      Supplementary Data

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