暨大九型九剑九选治疗体系③|郑小飞教授：关节镜下距腓前韧带缝合增强修复与暨大改良缝合增强修复在慢性踝关节不稳定中的临床结果对比

本期暨大九型九剑九选治疗体系专题栏目带来郑小飞教授团队一项临床研究成果——《Clinical outcomes of arthroscopic all-inside anterior talofibular ligament suture augmentation repair versus modified suture augmentation repair for chronic ankle instability patients》，暨南大学附属第一医院运动医学科踝关节镜团队侯辉歌主任通过比较关节镜下距腓前韧带普通缝合增强修复和暨大改良缝合增强修复在慢性踝关节不稳定（CAI）患者中的临床疗效，研究发现暨大改良缝合增强修复和普通缝合增强修复均显示出良好的临床疗效，暨大改良缝合增强修复组的AOFAS评分优于传统普通缝合增强修复组，为慢性踝关节不稳定（CAI）患者治疗方法提供了的新的选择策略。

Chronic ankleinstability(CAI)isaperceptionof“giv-ingway,”usuallyresultingfromlaxityorinjuryofliga-mentsaroundtheankle joint^[1]. Moreover,thedamageof anteriortalofibularligament(ATFL), whichischarac-terizedbymechanicalinstabilityof theankle joint,isanimportant cause of CAI that interferes withtheactivities ofdailyliving ^[1–4]. Approximately 40% of patients with untreated ankle sprains later develop CAI ^[5]. Currently, the management of CAI involves both surgical and non- surgical treatments  ^[6].  Nonsurgical treatments  mainly comprise physical therapy and taping ^[7]. However, sur- gical treatments have better outcomes than nonsurgical treatments in patients with CAI  ^[6]. Therefore,severalmodified surgical techniques have beendescribedearlierowingtothechallengesfacedbyorthopedicsurgeonsinchoosinganappropriatesurgical technique for theman- agementofpatientswithCAI ^[8–11].

In 2018, Vegaetal. werethepioneersinusingtheATFLsutureaugmentationrepairtechnique viaanklearthros-copy to treat patientswithCAIandachievedgoodclini-caloutcomes ^[12]. However, suture augmentation repair is not applicable in all cases ^[13]. Inclinicalpractice,wehavefoundthatstitchingtheupperandlowertractsoftheATFLintoasingleunitallowstheforcesof tractiontobetransferredfromtheATFLtothecalcaneofibularligament(CFL).This greatly enhances thestabilityof therepaired ATFL. Werefertothismethodasthemodifiedsutureaugmentationrepairtechnique,whichhasbeenapplied in the treatment of patients with CAI. Comparedtomodifiedsutureaugmentationrepair,sutureaugmen-tationonlyrepairedthedamagedupperorlowertractsof the ATFL. At present, studies on the clinical efficacy ofthesetwosurgicalschemesarescarce,andanobjective evaluation is lacking.

Therefore, in this study we aimed tocomparetheclini-calefficacyofarthroscopicsutureaugmentationrepairandmodified  sutureaugmentationrepairtoprovidea guidelinefororthopedicsurgeonstochooseappropriatesurgical  techniques.  Additionally,  it  has  been  hypoth-esized  that  modified  sutureaugmentation  repairmayachieve better clinical outcomes than conventional suture augmentation repair.

This single-center retrospective study aimed to evaluate the clinical efficacies of suture augmentation and modi- fiedsuture augmentation repairs.

We included  103 patients out of 196 inpatients with orthopedic disorders who visited our hospital between October 2019 and August 2020. Three patients, including those with arthritis  (n = 2) and systemic disease  (n = 1), were excluded.

Before performing surgeries, data pertaining to all par- ticipants were collected after obtaining written informed consents,  according  to  the principles of the  Declara- tion of Helsinki. Subsequently, propensity score match- ing (PSM) was applied, and a logistic regression model was used to achieve a balanced group at baseline. Age, sex, body mass index   (BMI),  preoperative  American Orthopedic Foot and Ankle Society (AOFAS) score, and preoperative  anterior  drawer  test  grade were  the  final covariates. The PSM ratio was 1:1 with a caliper width of 0.05. Ultimately, 100 patients with CAI (50 patients who underwent suture augmentation repair and 50 patients who  underwent  modified  suture  augmentation  repair) were included in this study. The surgical technique was decided by the same senior orthopedic surgeon.

The inclusion criteria were as follows: (1) patients with a history of CAI or ankle sprain in the past 6 months who were unresponsive to conservative treatment; (2) age < 60 years; (3) patients with no previous history of ankle sur- gery;  and  (4)  stress  radiographic  evaluation  findings showing that the difference in thetalar tilt angle was 10° and the absolute talar tilt angle was 15° between the two ankle laxities. The exclusion criteria were as follows: (1) patients with ankle osteoarthritis or anatomical deformi- ties such as sepsis, rheumatoid arthritis, and tuberculosis arthritis; and (2) patients with pre-existing medical con- ditions such as systemic or neuromuscular diseases or obesity that affected prognosis.

Modified suture augmentation (MSA) repair

The patient was placed under general anesthesia before the surgery, and the ankle joint was placed in the dorsi- flexion and lateral decubitus positions.

The  standard  anteromedial  (at  the  distal end  of the ankle line and close to the lateral side of the third pero- neal muscle tendon), anterolateral (at the level of 0.5 cm at the distal end of the ankle line and close to the lateral side of the third peroneal muscle tendon),and accessory anterolateral portals (at the level of 0.5 cm at the distal end of the ankle line, close to the anterior side of the fib-

ula and 1.0 cm away from the fibular tip) were carefully established to prevent damage to the superficial peroneal nerve.

A cannula was inserted through the anterolateral por- tal, and an arthroscope (Arthrex, 28,731 BWA, 4.0 mm) was used to visualize the structure of the articular cav- ity. Subsequently,  the  lateral  gutter was  exposed,  and the lateral  articular  capsule was  opened. A  slim guide needle was used first, and a No. 0 non-absorbable suture (Smith & Nephew, Arthrex)was folded in half using a lumbar puncture  needle  (Zhejiang  Runqiang Medical Instrument, 17G). The lumbar punctureneedle wasthenpassed through the inferior fascicle ofthe ATFL from theoutsidetoinside.Next,usinganarthroscopicgripper,No.0suture wascapturedthroughtheaccessory portal,where the folded suture ended to form a ferrule. A threadgrabber(Johnson 214,626) was usedtopullbothendsofthe suture out ofthe ferrule and then out ofthe accessoryportal. It could beobserved thattheligament wastightlygraspedbythesuture.Subsequently,aknotlessanchor(Pushlock2.9mmx  15mm,Arthrex)wasintroducedthrough a suture passer, and the ligament was repaired.

During anchoring, drilling at the center of the ATFL attachment  was  performed  by  employing  safety  inser- tion angles of 30° from the fibular longitudinal axis. The sutures were  threaded  through  an  anchor.  After  the anchors were implanted, both ends were sutured without cutting. The drill guide was inserted through the antero- lateral portal and placed at the center of thetalar neck to avoid invasion of the subtalar joint. The hole was drilled,and the bone anchor with the suture was passed throughtheportal veinandintroducedintothecavity by impac-tion.Finally,thesutureendswerecut,andtheincisionwas closed. The operational diagram is shown in Fig. 1.

Fig. 1  The operation diagram formodified suture augmentationrepair. A,B, C,D:TheNo. 0non-absorbable suture wasintroduced through theinferiorfascicle of ATFL;E,F, G,H:Theknotless anchor was introduced, and ATFL wasrepaired. ATFL: AnteriorTalofibularLigament. f: fibula; t:talus; ①: suturing theupper and lower tracts of the ATFL as a whole

ATFL suture augmentation (SA) repair

Except for the opening of the lateral joint capsule, all sur- gical procedures were similar to those of modified suture augmentation repair.  Therefore,  the  lumbar  puncture needle was passed through the superior fascicle of the ATFL from the outside to inside. The operational dia- gram is shown in Fig. 2.

Fig. 2  The operation diagram for suture augmentation repair. A: The operation diagram. B: Arthroscopic operation. @: only repaired the damaged upper tract of ATFL

ATFL suture augmentation (SA) repair

Except for the opening of the lateral joint capsule, all sur- gical procedures were similar to those of modified suture augmentation  repair.  Therefore,  the  lumbar  puncture needle was passed through the superior fascicle of the ATFL from the outside to inside. The operational dia- gram is shown in Fig. 2.

A non–weight-bearing, short-leg cast was  applied  on the ankle in a neutral position. After two weeks, the cast was replaced with a controlled ankle movement (CAM) boot. A gradual physical therapy program involving low- impact  ankle range  of  motion  and  strengthening  was initiated.Depending  on  the  progress,  the  supportive boot was removed after 4–6 weeks and the patient was allowed to return to normal activities of daily living.

The patientsreturnedtothehospitalforfollow-upat1,3,6,12,and24monthspostoperatively,andtheclinical outcomes at the last follow-up were recorded.

The American orthopedic foot & ankle society (AOFAS)

The AOFAS is primarily used to evaluate the functional status of the feet and ankles. It has a total score of 100 points and comprises three subscales: pain, function, and alignment^[14]. Overall, a score of 90–100 points is con- sidered “excellent,” a score of 80–90 points is considered “good,” a score of 60–80 points is considered “fair,” and a score of < 60 points is considered “bad” ^[14].

Visual analog scale (VAS)

The VAS  was  used  to  assess  the  pain  status  of  the patients. It consists of 0–10 points, 0 points for no pain, and 10 points for severe pain ^{[15, 16]}.

Anterior drawer test

The anterior drawer test is one of the methods used to evaluate ankle instability in patients. While performing the test, the patient is seated with the lower leg hanging over the edge of the examination bed. The doctor stabi- lizes the patient’sdistal tibia with one hand and applies an anterior force to the calcaneus with the other hand^[17]. It is mainly divided into four grades: Grade 0 (trans- lation  is  less  than  5  mm  compared with  the  opposite side), Grade 1 (translation 5–10 mm), Grade 2 (transla- tion 10–15 mm),and Grade 3 (translation > 15 mm) ^[18].

SPSS (IBM, Armonk, NY, USA) and  GraphPad  Prism (GraphPad  Software, San  Diego,  CA,  USA) were  used for the data analysis. The t-test was used to compare the clinical outcomes of age, follow-up time, AOFAS scores, and VAS scores. The chi-squared test was used to ana- lyze  the  anterior  drawer test  scores.  The  normality  of the distribution was evaluated using the Shapiro–Wilk test. PASS (PASS package, NCSS, USA) was used for the power analysis. The bilateral αvalue was 0.05, sample size was  100 and the test efficacy was 90%. In our study, a P-value< 0.05 was considered statistically significant.

One  hundred  patients  (59  men  and  41  women)  from October 2019 to August 2020 were included in the study after PSM (Fig. 3). Among them, 50 patients underwent suture augmentation  repair  (29  men  and  21  women, follow-up duration:  24.3±2.0 months),  and the other 50 underwent modified suture augmentation   repair (30 men and 20 women,follow-up:24.2±1.9months). The two groups were comparable after PSM validation. There were no statistically significant differences in age,

follow-up time, BMI,preoperative AOFAS score,preop-erative VAS score, or preoperative anterior drawer test scores  between  the  two  groups  (P = n.s.).  The  baseline characteristics of these groups are presented in Table 1.

Fig. 3  Trial profile

The  mean  postoperative  AOFAS  score  of the  modi- fied suture augmentation repair group was significantly higher than that of the suture augmentation repair group (MSA group: 83.8 ± 11.3; SA group: 76.0 ± 11.3; P = 0.001) (Table 2; Fig. 4).

Fig. 4  The violin figure of AOFAS scores in the two groups at final follow-up after the operation. AOFAS: The American Orthopedic Foot & Ankle Society; SA: Suture Augmentation Repair; MSA: Modified Suture Augmentation Repair. The bar indicates SD (**P < 0.01)

The mean postoperative VAS score was 1.50 ± 0.6 in the modified suture augmentation repair group and 1.48 ± 0.6 in the mean augmentation repair group. There were no statistically significant differences between the two treat- ment groups (P = 0.863) (Table 2).

There was no statistically significant difference in the postoperative  anterior  drawer  test  results between  the two groups (P = 0.617). As shown in Table 2 and 47 (94%) patients had grade 1 laxity, and three (6%) patients had grade 2 laxity in the modified suture augmentation repair group. Simultaneously, 45 (90%) and five (10%) patients had grade 1 and grade 2 laxity, respectively.

In terms of complications, three patients with CAI had superficial wound infections and one patient had sural nerve  injury in the  suture  augmentation  repair  group. Two patients in the modified suture augmentation repair group had superficial wound infections (Table 2).

The majorcontributionofthisstudyistheproposalofamodifiedsurgicaltechniquefortreatingpatientswithCAI. The clinical efficaciesof modified sutureaugmenta-tionrepairandsutureaugmentationrepairwereevalu- ated and compared.

Currently, a few surgical techniques for treating CAI, such  as lateral  ankle ligament  reconstruction  ^[19],  the modified  Karlsson  procedure ^[20],  modified  Broström procedures ^[21], and arthroscopic ATFL suture augmen- tation repair  ^[12], have been proposed. Although these surgical  techniques  have  demonstrated  good  clinical outcomes, postoperative complications such as immuno- genic reactions, infection, or recurrence are still reported to occur ^{[19, 22]}. Therefore, strategies must be developed to avoid such complications. Cordier et al. ^[23] demon-strated that the connectome between the lower bundle of theATFLandCFLissufficientlystrongtotransferten-sion from the ATFL to the CFL. Our research team found that suturing the upper and lowertractsof the ATFLfol-lowed by sutureaugmentationrepairnotonly effectivelypreventstherepairedATFLfromcolliding withthesur-roundingtissuesbutalsomakestherepairedATFLfirmandstable.Thissurgicalprocedureisreferredtoasthemodified suture augmentation repair. However,theclini-calefficacyofthemodifiedsutureaugmentationrepairremains to be elucidated. Therefore, the clinical efficaciesofsutureaugmentationandmodifiedsutureaugmenta- tion repairs were examined in the present study.

Similar  to  Tian  et  al. ^[22]  and  Hou  et  al.   ^[11],  we achievedgoodclinicaloutcomesatthefinalfollow-upusing  modified  suture  augmentation  repair  in  patients withCAI  (AOFAS:86.5  [Tianetal.],85.9  [Houetal.]vs.83.8).Additionally,theAOFASscoreincreasedfromabaselinescoreof65.9to83.8inthemodifiedsutureaugmentationrepairgroup.Tosomeextent,thisfindingdemonstratesthefeasibilityandclinicalefficacyofthemodified  suture  augmentation  repair  technique.  How- ever,anatomicalresearchisessentialforevaluatingthefeasibilityof theCAIsurgicaltechnique ^[24]. Therefore, further studies are warranted to evaluate the biomechan- ical and anatomical reconstruction efficacy of the modi- fiedsuture augmentation repair.

In addition, weevaluated the postoperative visualana-log scale (VAS) and anterior drawer test scores in the twotreatment groups. Anterior drawer test scores showed nosignificantdifferencesbetweenthesutureaugmentationrepairandmodifiedsutureaugmentationrepairgroups.Although  grade  3laxity  wasnotobservedinall  the patients after surgery, grade 2 laxity was observed in bothtreatmentgroups.Thismaybeattributedtothepatientreturning  to  work  immediatelyorimproperrecoverymethodsaftersurgery ^[22]. Thisiswhereweshouldpayattention  to.  No  statistical  difference  was  observed  in termsoftheVASscorebetweenthetwosurgicaltech-niques.  In  general,  clinical  results  show  that  modified suture augmentation repair is feasible.

Modified sutureaugmentationrepairisanimprovedtechniquebasedonsutureaugmentationrepair.There-fore,itisnotdifficultfororthopedicsurgeonstomasterthis surgical technique. However, thenatureof the ATFLinjury in each patient isdifferent; therefore,theselectionof the surgical scheme should bebasedontheindividualsituationof thepatient.Moreover,afewpatientsinthisstudyhadpostoperativecomplications,suchassuperfi-cial wound infectionsandsural nervedamage,similartothoseinthestudy byTianetal.^[22]. It is worth consid- ering methods to reduce the incidence of postoperative complications.

This  studyhassomelimitations.First,thefollow-uptime  was  approximately24months,andfurtherfol- low-upsareneededasthisisanewlyintroducedmodi-fiedsurgicaltechnique.Second,thiswasasingle-centerretrospective  trial  with  a  limited  number  of  patients.Therefore,additionalmulticenter-controlled  trials   arewarranted.Nevertheless,wereportpromisingclini- caloutcomesforthismodifiedCAIsurgicaltechnique.Basedonourstudy results, thistechniquemay beappli-cable to patients with CAI for whomother treatments are not feasible. Further studies are warranted to validate this surgical technique.

Both modified suture augmentation and sutureaugmen- tation  repairs  are  good  treatment  options  for  patients with  CAI.  Our preliminary data indicate that  superior AOFAS scores were obtained with the use of modified suture augmentation repair as compared with suture aug- mentation repair. This newly introduced modified surgi-cal technique is a feasible and practical treatment option for patients with CAI.