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Abstract & Commentary
Synopsis: Operative treatment appears to provide no significant advantage over nonoperative treatment for an isolated injury of the fibular collateral ligaments of the ankle; therefore, the less costly and risky nonoperative course should be pursued.
Source: Povacz P, et al. A randomized, prospective study of operative and nonoperative treatment of injuries of the fibular collateral ligaments of the ankle. J Bone Joint Surg 1998;80-A(3):345-351.
A prospective, randomized comparison of operative and nonoperative treatment of acutely torn lateral collateral ligaments of the ankle was carried out in 146 adults. These were isolated injuries of the fibular collateral ligaments ranging from moderate to severe as measured by an objective stress test that quantified the degree of talar tilt. Patients were randomly assigned to operative or nonoperative treatment groups. Operative treatment included surgical repair of the disrupted ligaments within 72 hours of the injury combined with plaster cast immobilization for six weeks. For the nonoperative treatment, the patients were given an elastic wrap and then placed in an air cast 3-7 days after the injury and told to wear the brace for six weeks. The patients were followed for a minimum of two years, and there were no detectable differences between the two groups with regard to the degree of joint laxity, as measured on stress x-ray, or functional results. The only significant difference between the two groups was the amount of time lost from work with the operative group being out of work for an average of seven weeks post injury while the nonoperative group lost a mean of only 1.6 weeks. Povacz and associates conclude that operative treatment provides no significant advantage over nonoperative treatment for an isolated injury of the fibular collateral ligaments of the ankle.
Over the last few years, there has been increasing interest, at least among some surgeons, in moving forward quickly with surgical repair of acutely torn, grossly unstable lateral ankle ligaments, especially in competitive athletes. Surgical intervention has been justified by the belief that early repair allows return to full levels of competition at an earlier stage. Most of the patients in this series were young adults who sustained their injuries during athletic activity. The number of severe ankle sprains, as demonstrated by complete instability of the ankle (a tibiotalar tilt of more than 20°) was relatively small (17 in the nonoperative group and 19 in the operative group). But even the results in this subgroup of patients showed no difference between the two methods of treatment. While it is difficult, if not impossible, to absolutely prove that there is no difference between any two treatment methods, the fact that no statistically significant differences were noted in the study leads me to conclude that regardless of the severity of a lateral ankle sprain, even in a competitive athlete, there is no need to proceed immediately with surgical repair. There is a good chance that the athlete will recover to his or her previous functional level with closed treatment. Until such time as studies such as this clearly demonstrate an advantage of surgical treatment over nonoperative treatment, the less costly and less risky nonoperative course should be pursued.