Vopat Matthew L, Wendling Alexander, Lee Brennan, Hassan Maaz, Morris Brandon, Tarakemeh Armin, Zackula Rosey, Mullen Scott, Schroeppel Paul, Vopat Bryan G
Department of Orthopaedics, University of Kansas School of Medicine-Wichita, Wichita, KS.
Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS.
Kans J Med. 2021 Jun 21;14(2):141-148. doi: 10.17161/kjm.vol1415028. eCollection 2021.
Lateral ankle instability represents a common orthopaedic diagnosis. Nonoperative treatment through focused physical therapy provides satisfactory results in most patients. However, some patients experience persistent chronic lateral ankle instability despite appropriate nonoperative treatment. These patients may require stabilization, which can include primary lateral ligament reconstruction with a graft to restore ankle stability. Optimal post-operative rehabilitation of lateral ankle ligament reconstruction remains unknown, as surgeons vary in how long they immobilize their patients post-operatively. The aim of this review was to provide insight into early mobilization (EM) versus delayed mobilization (DM) post-operative protocols in patients undergoing primary lateral ankle ligament reconstructions to determine if an optimal evidence-based post-operative rehabilitation protocol exists in the literature.
Following PRIMSA criteria, a systematic review/meta-analysis using the PubMed/Ovid Medline database was performed (10/11/1947 - 1/28/2020). 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 three weeks of surgery) and delayed mobilization (after three weeks of surgery). Functional outcome scores (American Orthopedic Foot and Ankle Society Score (AOFAS), Karlsson scores), radiographic measurements (anterior drawer, talar tilt), and complications were evaluated using weighted mean differences (pre- and post-operative scores) and mixed-effect models.
After our search, twelve out of 1,574 studies met the criteria for the final analysis, representing 399 patients undergoing lateral ankle reconstruction. Using weighted mean differences the DM group showed superior AOFAS functional scores compared to the EM group (28.0 (5.5) vs. 26.3 (0.0), respectively; p < 0.001), although sample size was small. Conversely, no significant differences were found for Karlsson functional score (p = 0.246). With regards to radiographic outcome, no significant differences were observed; anterior drawer was p = 0.244 and talar tilt was p = 0.937. A meta-analysis using mixed-effects models confirmed these results, although heterogeneity was high.
While there are some conflicting results, the findings indicated the timing of post-operative mobilization made no difference in functional outcomes or post-operative stability for patients undergoing lateral ankle ligament reconstruction. Because heterogeneity was high, future studies are needed to evaluate these protocols in less diverse patient groups and/or more consistent techniques for lateral ankle ligament reconstruction.
外侧踝关节不稳是一种常见的骨科诊断。通过针对性的物理治疗进行非手术治疗，在大多数患者中能取得满意的效果。然而，一些患者尽管接受了适当的非手术治疗，仍会出现持续性慢性外侧踝关节不稳。这些患者可能需要进行稳定手术，其中可包括使用移植物进行一期外侧韧带重建以恢复踝关节稳定性。外侧踝关节韧带重建术后的最佳康复方案仍不明确，因为外科医生在术后固定患者的时间长短上存在差异。本综述的目的是深入了解接受一期外侧踝关节韧带重建的患者术后早期活动（EM）与延迟活动（DM）方案，以确定文献中是否存在基于证据的最佳术后康复方案。
按照PRISMA标准，使用PubMed/Ovid Medline数据库进行系统综述/荟萃分析（1947年10月11日至2020年1月28日）。排除重复、非外侧韧带修复、生物力学及非英文的手稿。对方案进行审查并分为两类：早期活动（术后三周内）和延迟活动（术后三周后）。使用加权平均差（术前和术后评分）和混合效应模型评估功能结局评分（美国矫形足踝协会评分（AOFAS）、卡尔森评分）、影像学测量（前抽屉试验、距骨倾斜）及并发症。
在检索后，1574项研究中有12项符合最终分析标准，代表399例接受外侧踝关节重建的患者。使用加权平均差，DM组的AOFAS功能评分优于EM组（分别为28.0（5.5）和26.3（0.0）；p<0.001），尽管样本量较小。相反，卡尔森功能评分未发现显著差异（p = 0.246）。关于影像学结局，未观察到显著差异；前抽屉试验p = 0.244，距骨倾斜p = 0.937。使用混合效应模型的荟萃分析证实了这些结果，但异质性较高。
虽然存在一些相互矛盾的结果，但研究结果表明，对于接受外侧踝关节韧带重建的患者，术后活动时间对功能结局或术后稳定性没有影响。由于异质性较高，未来需要在患者群体差异较小和/或外侧踝关节韧带重建技术更一致的情况下评估这些方案。
