Evolution in Surgical Management of Ankle Instability in Athletes

Brian C. Lau, MD; Alexej Barg, MD; C. Thomas Haytmanek, MD; Kirk McCullough, MD; Annunziato Amendola, MD


J Am Acad Orthop Surg. 2021;29(1):e5-e13. 

In This Article

Use of Suture Tape Augmentation

Although the modified Broström procedure has been successful, there remains 5% to 10% of patients with recurrent instability.[17] Waldrop et al[14] conducted a biomechanical study of the intact anterior talofibular ligament (ATFL), bone tunnel Broström, and suture anchor repair Broström. They found that although suture anchors improved the construct, the repair remained nearly less than half that of an intact ATFL in ultimate strength and stiffness.[14] As such, attempts to improve the strength of the construct were sought, and the concept of a suture tape augmentation was initiated.

The suture tape is a braided ultrahigh molecular weight polyethylene polyester that was originally conceived as a method to allow immediate fixation of acutely torn ligaments to allow earlier return to sport. This concept has now evolved to become a method to augment reconstruction of chronic instability. Biomechanical data from Viens et al[18] confirmed that a Broström repair augmented with a suture tape restored ultimate failure and stiffness to the level of an intact ATFL. These findings were supported by a follow-up biomechanical study by Schuh et al[19] who reported that the suture tape augmented repairs demonstrated superior strength for angle of failure and amount of torque applied at time of failure. In addition, Lohrer et al,[20] using a three-dimensional analysis of an anterior talar drawer found that the augmented repair protected against instability of the ankle in the sagittal plane.

Clinical results also support the effectiveness of the augmented repair. Coetzee et al[6] evaluated 81 patients who hand undergone a Broström procedure that had been augmented with a suture tape. At the follow-up (mean = 11.5 months), visual analog scale (VAS) scores and range of motion were satisfactory, patients returned to sports were at a mean of 84.1 days, and 86.4% of patients achieved limb symmetry on single-leg hop. The suture tape augmented repair, however, had decreased dorsiflexion compared with the nonoperative side (9.2 versus 10.4 cm). The authors concluded that the augmented repair was safe and effective but could possibly lead to overconstraint.[6]

Several authors have found no significant difference in suture anchor lateral ligament repair with and without suture tape augmentation.[21,22] Xu et al[22] conducted a retrospective review comparing 25 patients after a modified Broström with suture tape augmentation against 28 patients treated with a modified Broström repair with suture anchors. The suture tape augmentation patients demonstrated improved Foot and Ankle Ability Measure (FAAM) Sport (difference of 8.9) and total scores (difference of 2.6). All other outcome measures (American Orthopaedic Foot & Ankle Society [AOFAS], range of motion, VAS, talar tilt, and anterior talar translation on stress radiographs) showed no significant differences. Cho et al[21] conducted a randomized trial in young (mean age = 26.9 years) female patients with chronic ankle instability. Patients were randomly assigned to undergo a minimally invasive technique of suture tape application and a modified Broström repair (n = 28) or isolated suture anchors (n = 27). At a mean of 36.6 months after surgery, no group differences were noted in Foot and Ankle Outcome Score (FAOS), FAAM, recurrence rate of instability, and anterior drawer or talar tilt on stress radiographs. The suture-tape augmentation repair was, however, 1.3× more expensive.[21]

Cho et al[23] have also evaluated whether suture tape augmentation may be beneficial in a cohort at risk for surgical failure. They evaluated 28 patients with generalized ligament laxity (Beighton score ≥ 4) after undergoing an augmented modified Broström procedure for chronic ankle instability. At the final (2-year) follow-up, FAOS and FAAM scores were both improved. Talar tilt and anterior talar translation on stress radiographs also improved. In this high-risk cohort with generalized laxity, only one patient (3.6%) developed recurrence after surgical repair with suture anchors and suture tape augmentation. In a separate study, the group of Cho evaluated the effectiveness of a suture tape augmented repair in 30 patients with persistent instability after a failed Broström procedure.[24] At a mean of 38.5 months, FAOS and FAAM scores improved. Talar tilt and anterior talar translation also improved with no significant differences when compared with the contralateral side. Only one patient failed and underwent revision reconstruction with allograft tendon.[24]

Biomechanical cadaver-based testing demonstrates suture tape augmentation has greater strength compared with suture anchor or traditional modified Broström repairs. Early clinical data showed that an improvement in stability was noted, but when compared with suture anchor or the traditional modified Broström, subjective outcomes and strength results were equivocal. Suture tape augmentation may also be beneficial for patients considered to be at risk, for example, for patients with generalized laxity or revision cases.