What is the optimal treatment for lateral ankle ligament ruptures?

BACKGROUND: The nearly 23,000 daily ankle injuries in the United States account for approximately 25% of all musculoskeletal injuries. The anterior talofibular ligament (a lateral supporting ligament) is most often involved. Current management options include casting, surgery, functional treatment, or minimal-to-no treatment. Despite recently published reviews suggesting that functional treatment and early mobilization provide the best results, other studies recommend operative treatment. This meta-analysis was designed to systematically determine the best treatment approach.

POPULATION STUDIED: More than 3300 patients with acute lateral ankle ligament ruptures enrolled in 27 randomized controlled trials were evaluated. Fifteen of the 42 trials initially identified were excluded because of poor follow-up (<40% dropout), republication of the same trial, or lack of relevant outcome variables. Diagnosis based on imaging by an arthrogram or stress radiograph was required. Study duration ranged from 6 to 46 months. Articles were included regardless of published language. Patients were largely recruited from the general population, so the results likely apply to those managed by family physicians.

STUDY DESIGN AND VALIDITY: The authors of this meta-analysis reviewed randomized controlled trials found by searching the MEDLINE, Cochrane, and EMBASE databases from 1966 to 1998. Three independent investigators blinded to author and institution reviewed each trial and assessed its quality. Quality was determined by randomization that included concealed allocation assignment, adequate follow-up, and blinded outcome assessment. Treatments included operative (using a similar surgical protocol), casting for 6 weeks, and different types of functional intervention (bracing, wrapping, orthoses such as air casts, special shoes, and cast immobilization for 3 weeks). Three methods employing minimal treatment (less than 3 weeks of socks, braces, wraps, or casts) were also included because no trials of nonintervention were identified. Data were analyzed for homogeneity by calculating the Q statistic.

OUTCOMES MEASURED: The authors evaluated 2 long-term outcomes (residual pain and giving way) and one short-term outcome (time lost from work).

RESULTS: The natural history of untreated lateral ankle ligament ruptures is unknown. Treatments of short duration or inadequate ankle joint support are associated with more frequent residual symptoms (pain and giving way). Operative treatment followed by functional treatment resulted in less giving way than functional treatment alone (relative risk [RR]=0.23; 95% confidence interval [CI], 0.17-0.31). Functional treatment alone led to less giving way than 6-week cast treatment (RR=0.69; 95% CI, 0.50-0.94). Functional treatment was also associated with less pain than 6-week cast treatment (RR=0.67; 95% CI, 0.50-0.90). No other differences between interventions were found with regard to pain. Time lost from work varied greatly. Approximately 10% of patients undergoing operative treatment developed surgical complications. Results of a subgroup analysis of the high-quality studies only were not different from the results of the corresponding analysis of all studies.

BACKGROUND: The nearly 23,000 daily ankle injuries in the United States account for approximately 25% of all musculoskeletal injuries. The anterior talofibular ligament (a lateral supporting ligament) is most often involved. Current management options include casting, surgery, functional treatment, or minimal-to-no treatment. Despite recently published reviews suggesting that functional treatment and early mobilization provide the best results, other studies recommend operative treatment. This meta-analysis was designed to systematically determine the best treatment approach.

POPULATION STUDIED: More than 3300 patients with acute lateral ankle ligament ruptures enrolled in 27 randomized controlled trials were evaluated. Fifteen of the 42 trials initially identified were excluded because of poor follow-up (<40% dropout), republication of the same trial, or lack of relevant outcome variables. Diagnosis based on imaging by an arthrogram or stress radiograph was required. Study duration ranged from 6 to 46 months. Articles were included regardless of published language. Patients were largely recruited from the general population, so the results likely apply to those managed by family physicians.

STUDY DESIGN AND VALIDITY: The authors of this meta-analysis reviewed randomized controlled trials found by searching the MEDLINE, Cochrane, and EMBASE databases from 1966 to 1998. Three independent investigators blinded to author and institution reviewed each trial and assessed its quality. Quality was determined by randomization that included concealed allocation assignment, adequate follow-up, and blinded outcome assessment. Treatments included operative (using a similar surgical protocol), casting for 6 weeks, and different types of functional intervention (bracing, wrapping, orthoses such as air casts, special shoes, and cast immobilization for 3 weeks). Three methods employing minimal treatment (less than 3 weeks of socks, braces, wraps, or casts) were also included because no trials of nonintervention were identified. Data were analyzed for homogeneity by calculating the Q statistic.

OUTCOMES MEASURED: The authors evaluated 2 long-term outcomes (residual pain and giving way) and one short-term outcome (time lost from work).

RESULTS: The natural history of untreated lateral ankle ligament ruptures is unknown. Treatments of short duration or inadequate ankle joint support are associated with more frequent residual symptoms (pain and giving way). Operative treatment followed by functional treatment resulted in less giving way than functional treatment alone (relative risk [RR]=0.23; 95% confidence interval [CI], 0.17-0.31). Functional treatment alone led to less giving way than 6-week cast treatment (RR=0.69; 95% CI, 0.50-0.94). Functional treatment was also associated with less pain than 6-week cast treatment (RR=0.67; 95% CI, 0.50-0.90). No other differences between interventions were found with regard to pain. Time lost from work varied greatly. Approximately 10% of patients undergoing operative treatment developed surgical complications. Results of a subgroup analysis of the high-quality studies only were not different from the results of the corresponding analysis of all studies.

BACKGROUND: The nearly 23,000 daily ankle injuries in the United States account for approximately 25% of all musculoskeletal injuries. The anterior talofibular ligament (a lateral supporting ligament) is most often involved. Current management options include casting, surgery, functional treatment, or minimal-to-no treatment. Despite recently published reviews suggesting that functional treatment and early mobilization provide the best results, other studies recommend operative treatment. This meta-analysis was designed to systematically determine the best treatment approach.

POPULATION STUDIED: More than 3300 patients with acute lateral ankle ligament ruptures enrolled in 27 randomized controlled trials were evaluated. Fifteen of the 42 trials initially identified were excluded because of poor follow-up (<40% dropout), republication of the same trial, or lack of relevant outcome variables. Diagnosis based on imaging by an arthrogram or stress radiograph was required. Study duration ranged from 6 to 46 months. Articles were included regardless of published language. Patients were largely recruited from the general population, so the results likely apply to those managed by family physicians.

STUDY DESIGN AND VALIDITY: The authors of this meta-analysis reviewed randomized controlled trials found by searching the MEDLINE, Cochrane, and EMBASE databases from 1966 to 1998. Three independent investigators blinded to author and institution reviewed each trial and assessed its quality. Quality was determined by randomization that included concealed allocation assignment, adequate follow-up, and blinded outcome assessment. Treatments included operative (using a similar surgical protocol), casting for 6 weeks, and different types of functional intervention (bracing, wrapping, orthoses such as air casts, special shoes, and cast immobilization for 3 weeks). Three methods employing minimal treatment (less than 3 weeks of socks, braces, wraps, or casts) were also included because no trials of nonintervention were identified. Data were analyzed for homogeneity by calculating the Q statistic.

OUTCOMES MEASURED: The authors evaluated 2 long-term outcomes (residual pain and giving way) and one short-term outcome (time lost from work).

RESULTS: The natural history of untreated lateral ankle ligament ruptures is unknown. Treatments of short duration or inadequate ankle joint support are associated with more frequent residual symptoms (pain and giving way). Operative treatment followed by functional treatment resulted in less giving way than functional treatment alone (relative risk [RR]=0.23; 95% confidence interval [CI], 0.17-0.31). Functional treatment alone led to less giving way than 6-week cast treatment (RR=0.69; 95% CI, 0.50-0.94). Functional treatment was also associated with less pain than 6-week cast treatment (RR=0.67; 95% CI, 0.50-0.90). No other differences between interventions were found with regard to pain. Time lost from work varied greatly. Approximately 10% of patients undergoing operative treatment developed surgical complications. Results of a subgroup analysis of the high-quality studies only were not different from the results of the corresponding analysis of all studies.