Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults

 

Abstract

Background

Ankle sprains are one of the most commonly treated musculoskeletal injuries. The three main treatment modalities for acute lateral ankle ligament injuries are immobilisation with plaster cast or splint, 'functional treatment' comprising early mobilisation and use of an external support (e.g. ankle brace), and surgical repair or reconstruction.

Objectives

We aimed to compare surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2006), the Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to December 2005), EMBASE, CINAHL and reference lists of articles, and contacted researchers in the field. This review is considered updated to January 2006.

Selection criteria

Randomised or quasi-randomised controlled trials comparing surgical with conservative interventions for treating ankle sprains in adults.

Data collection and analysis

At least two authors independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled. We performed sensitivity analyses to explore the robustness of the findings.

Main results

Twenty trials were included. These involved a total of 2562 mostly young active adult males. All trials had methodological weaknesses. Specifically, concealment of allocation was confirmed in only one trial. Data for pooling individual outcomes were only available for a maximum of 12 trials and under 60% of participants.

The findings of statistically significant differences in favour of the surgical treatment group for the four primary outcomes (non-return to pre-injury level of sports; ankle sprain recurrence; long-term pain; subjective or functional instability) when using the fixed-effect model were not robust when using the random-effects model, nor on the removal of one low quality (quasi-randomised) trial that had more extreme results. A corresponding drop in the I² statistics showed the remaining trials to be more homogeneous.

The functional implications of the statistically significantly higher incidence of objective instability in conservatively treated trial participants are uncertain. There was some limited evidence for longer recovery times, and higher incidences of ankle stiffness, impaired ankle mobility and complications in the surgical treatment group.

Authors' conclusions

There is insufficient evidence available from randomised controlled trials to determine the relative effectiveness of surgical and conservative treatment for acute injuries of the lateral ligament complex of the ankle. High quality randomised controlled trials of primary surgical repair versus the best available conservative treatment for well-defined injuries are required.

 

Plain language summary

Surgery versus conservative treatment for acute ankle sprains in adults

Ankle sprain is one of the commonest musculoskeletal injuries in active people. It generally involves damage to the lateral or outer ligaments, which connect bones together on the outside of the ankle joint. Treatment is usually either immobilisation of the leg in a plaster cast, or 'functional treatment' where the ankle is kept in use while protected by an external support. After treatment, however, some people still have a weak and sometimes painful ankle. This review aimed to find out if primary surgical repair of the torn ligament(s) gives a better result than either of these two non-surgical or conservative treatments.

Twenty trials were included. These involved a total of 2562 mostly young active adult males. All trials had methodological flaws that could have affected their results. Data for pooling individual outcomes were only available for a maximum of 12 trials. Additionally, there was one low quality and potentially biased trial with very positive results in favour of surgery. When this trial was excluded, the findings of better results for surgery in terms of return to sports, re-injury, persistent pain and ankle instability as judged by the patient were no longer statistically significant. Thus, the trend to a better result from surgery remains unproven. Ankle stability, as judged by the clinician using standard tests, was better after surgery than with conservative treatment. Conversely, there was some limited evidence for longer recovery times, and higher incidences of ankle stiffness, impaired ankle mobility and complications in the surgical treatment group.

We concluded that there was not enough evidence from randomised controlled trials to say whether surgery gives a better result than conservative treatment for acute ankle sprain in adults.

 

摘要

背景

對成人急性踝外側韌帶損傷的手術與保守治療的比較

踝關節扭傷是一種最常見需治療的骨骼肌肉傷害。對急性踝關節外側韌帶損傷有三個主要的治療方法：以石膏或夾板固定不動，‘功能性治療‘，包括早期活動和利用外部支持(如護踝)，和手術修復或重建。

目標

我們主要目的是比較成人急性踝外側韌帶損傷的手術與保守治療。

搜尋策略

我們搜查了Cochrane Bone, Joint and Muscle Trauma Group 專門登記(2006年一月)，中央臨床對照試驗(CENTRAL)(Cochrane圖書館2005年第4期), MEDLINE(1996年至2005年12月)， EMBASE， CINAHL ，和參考文獻目錄的文章，並聯絡各領域人員。這項回顧審查更新到2006年1月。

選擇標準

利用隨機或半隨機試驗，針對成人急性踝外側韌帶損傷的手術與保守治療的比較。

資料收集與分析

至少有兩個審閱者獨立評估方法的品質和提取數據，在適當情況下，匯集比較的研究結果，我們進行敏感性分析，探討調查結果的穩健性。

主要結論

二十個試驗被納入。這些涉及總額2562多為活動力強的年青成年男性。所有的試驗都有方法學上的弱點。具體來說，只在一個試驗確實有隱瞞分配。匯集個別成果的數據 最終至多12項試驗與小於60％的參與者可堪研究。當使用固定效應模型時，手術治療組在四個主要成果在統計上有顯著正向差異(非回到受傷前的運動水平、反復踝關節扭傷的發生、長期病痛、主觀或功能不穩定)，當使用隨機效應模型或去除一個低品質(半隨機)並產生極端結果的試驗，則並不強勁。相應下降的I 2統計數據顯示其餘的試驗更加均勻。保守治療試驗參與者有客觀的不穩定出現較顯著高的統計發生率是不確定的。有限的證據顯示在外科治療組中有更長的恢復時間，腳踝僵硬的發生率較高，踝關節活動受損和併發症較多。

作者結論

從隨機對照試驗中沒有足夠的證據可以證實，對成人急性踝外側韌帶損傷的手術與保守治療的相對有效性的比較。仍須高品質的隨機對照試驗，以便評估對一個確定損傷後手術修補與現有的最佳保守治療的比較。

翻譯人

本摘要由林口長庚醫院許喻敦翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

對成人急性踝外側韌帶損傷的手術與保守治療的比較。 踝關節扭傷是一種最常見需治療的骨骼肌肉傷害。它通常包括損害連接踝關節的骨頭的外側或外層韌帶。主要的治療方法對急性踝關節外側韌帶損傷有：以石膏固定不動，‘功能性治療‘，包括早期活動和利用外部支持(如護踝)，然而治療後， 有些人仍然無力，甚至疼痛。這項回顧審查的目的是看看手術修復撕裂的韌帶是否比非手術或保守治療提供了較佳的效果。二十試驗被納入。這些涉及總額2562多為活動力強的年青成年男性。所有試驗有方法的缺陷其可能影響結果。匯集個別成果的數據僅最多12項試驗可得。此外，有一個低質量的和潛在偏見的試驗認為手術有非常積極的結果，即贊成手術。如由病人主觀判斷手術的結果：如回到受傷前的運動水平，再反復踝關節扭傷的發生、長期病痛、踝關節功能不穩定..等，則無明顯統計學意義。因此，手術有較好結果的趨勢仍然未能得到證實。踝關節穩定，使用標準的試驗及臨床判斷，手術比保守治療好。相反的，一些有限的證據顯示在外科治療組中有更長的恢復時間，腳踝僵硬的發生率較高，踝關節活動受損和併發症的證據。我們得出結論認為，隨機對照試驗說明，是否手術提供了比保守治療急性踝關節扭傷的成年人有較佳的結果，並沒有足夠的證據證實。