Abstract
Chronic lateral ankle instability (CLAI) is characterized by recurrent ankle sprains. Conservative treatment may result in persistent instability requiring operative management. Surgical treatments such as the Modified Brostrom-Gould (MB) procedure with and without suture tape ligament augmentation (+ST) have become effective at strengthening and/or supplementing repair. However, there is little evidence regarding a superior technique regarding cost-benefits for patients receiving either treatment. This review performed a comparative cost analysis between these procedures using Web of Science, PubMed, and Scopus databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 3 studies (257 ankles) met the inclusion criteria. Of the four groups (open MB, arthroscopic MB, MB+ST, MB+Mason-Allen), the MB+Mason-Allen suture technique appeared to be the most cost-effective, owed to shorter operating times and the use of only one suture anchor. There was no significant difference in post-operative Patient Reported Outcome Scores (PROMS) using AOFAS scores. However, there was a significant difference in the aggregate cost for patients who had open Brostrom-Gould and arthroscopic Brostrom-Gould, with open being overall lower cost. Furthermore, the MB group was $2219 more expensive than the MB+ST (FiberTape internal brace augmentation ($20,970 vs. $18,751)) groups. Overall, utilizing an open technique (as opposed to arthroscopic), only placing one suture anchor (via Mason Allen configuration repair), and well-indicated internal brace utilization offer advantageous cost-efficacy in lateral ankle ligamentous stabilization. However, these findings should be interpreted cautiously and thoroughly considered due to the paucity of data on reported studies.
Introduction
Ankle sprains are exceedingly common and may result in chronic lateral ankle instability (CLAI). For example, over 300,000 ankle sprains are reported in the UK’s Accident and Emergency Departments yearly. The most appropriate initial management includes conservative treatment and implementing a RICE (rest, ice, compression, elevation) method for recovery. However, repeated sprains (approximately 20 % of injuries) may cause CLAI with a subjective lack of confidence in performing pivoting movements. Physical therapy focusing on proprioceptive training has demonstrated high clinical efficacy for most patients. However, persistent instability despite an appropriate conservative treatment indicates operative intervention. Surgery involves repairing the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) with the incorporation of other anatomic structures (i.e., Gould modification) as indicated.
The modified Brostrom-Gould technique, an anatomical repair incorporating the inferior extensor retinaculum via 2–3 suture anchors, has gained popularity due to its predictable good outcomes and low complication profile. However, there are various lateral ankle stabilizing procedures that all appear to have equivalent outcomes. Since Brostrom first described the open surgical technique in 1966, arthroscopic modifications have been proposed. Arthroscopy-assisted surgery is relatively new, permitting the added intra-articular visualization; however, it may incur higher operating times and increased risk for iatrogenic nerve damage. , Further, novel implants, such as supplemental suture tape augmentation, have brought an additive consideration in operative treatment. Waldrop et al. demonstrated that suture anchors-only repair led to half of the stability gained from the original ATFL, whereas suture tape augmentation resulted in more biomechanically stable ATFLs and a quicker return to sports. Lastly, newer operative technique modifications, such as the MB/Mason-Allen suture technique, have gained popularity due to high satisfaction rates and cheaper costs for only using one-suture anchor.
It can be readily appreciated that there lacks a consistent gold-standard treatment option for CLAI. In most circumstances, it would be prudent to utilize the most cost-effective treatment option for these patients who lack concomitant pathologies requiring alternative treatments. Unfortunately, there has been a paucity of comparative studies concerning the cost-benefits of the various operative techniques for CLAI. As a result of this lack of evidence, this article sought to provide a systematic review comparing the reported costs of various lateral ankle ligamentous stabilization procedures.
Methods
A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines. The search included PubMed, Scopus, and Web of Science databases for all articles published between 2000 and May 2024. Keywords and phrases included “Brostrom” OR “ankle lateral ligament” AND “cost.” After removing duplicate studies, two authors searched, screened, and collected initial data. At least two authors screened each article title and abstract for inclusion and compiled a list of potential articles. Case reports, review articles, studies involving the cost of only nonoperative treatment, and any cohort studies lacking directly reported costs were excluded. Thereafter, each remaining full manuscript was screened by two authors for final inclusion ( Fig. 1 ). The senior author resolved any discrepancies. Single-data extraction was performed. Data were extracted regarding patient demographics, pertinent operative information, implants utilized, surgical technique, outcome scores, and adverse events. These included patient age, sex, procedure performed, implant utilized, operative time, time to return to work/sport, outcoming scoring, surgery costs, and complications. Due to the paucity of findings and heterogeneity in indications and surgical procedures performed, a meta-analysis was not performed.
Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram.
Results
Search results
The initial search yielded 220 abstracts, with 208 remaining after removing duplicates. Titles and abstract screening identified 22 publications eligible for full manuscript review, 3 of which ultimately met inclusion criteria and underwent data extraction ( Fig. 1 ). ,, These three studies were published in 2020 or more recently.
Reported operative procedures
Between the studies, 257 total pooled patients were included. Most reported patients were young adult males with a minimum one-year follow-up. The open Modified Brostrom procedure (MB; n = 161) was the most common surgery performed, followed by MB with suture tape internal brace augmentation (MB+ST; n = 49) and arthroscopic MB ( n = 17; Fig. 1 ).
Factors impacting reported costs
The predominant reported factors found to impact the overall cost of care included the operative approach (i.e., open vs. arthroscopic), the number of suture anchors utilized, and operative time. Factors that resulted in lower costs included open procedures (compared to arthroscopic), utilizing one suture anchor (rather than two), and adding suture tape augmentation.
Open vs. arthroscopic
Zeng et al. demonstrated that open procedures were more cost-effective than arthroscopic-assisted procedures ($2345.28 vs. $3004.50 in USD, respectively; Table 2 ). The authors owed this significantly lower cost to the open group being shorter surgeries than arthroscopic (31.7 ± 9.5 min vs. 53.8 ± 11.7 min, respectively). Despite the shorter operative time, they reported no significant difference in complication rates between groups ( Table 3 ). The open MB patients conveyed a 30 % (3/10) complication rate due to poor healing ( n = 2) and painful nodules ( n = 1). Arthroscopic patients demonstrated an 11.8 % (2/17) complication rate, resulting from poor healing ( n = 1) and nerve injury ( n = 1).
Number of suture anchors
Liu et al. reported a lower cost for operative treatment utilizing only one suture anchor via the MB/Mason-Allen technique as compared to standard two anchors used in the standard MB-alone technique ($2903.73 vs. $3853.61, respectively; Table 2 ). The authors owed this significantly lower cost to fewer implants and resultant shorter surgeries (27.0 ± 4.7 min vs. 41.5 ± 5.9 min, respectively; Table 2 ). Despite the shorter operative time, the authors reported no difference in hospital stay duration and without any complications in either group ( Table 3 ).
Suture tape augmentation
Vanatta et al. reported that MB with suture tape augmentation incurred a lowered overall cost of care compared to MB alone ($18,751 vs. $20,970). The authors did not report a significant difference in operative time between procedures. They attributed the lower cost to fewer physical therapy visits and less time missed from work in the suture tape group. They also found no significant difference between the complication rates (2.0 % for MB+ST vs. 3.4 % for MB) or AOFAS scores at the final follow-up ( Table 3 ).
Discussion
Lateral ankle instability requiring operative intervention remains common in the United States. Despite its prevalence, there is limited evidence regarding direct cost comparisons among the various lateral ankle ligamentous repair or reconstruction procedures. This systematic review found that the most cost-beneficial strategies were performing an open (rather than arthroscopic) MB technique, placing only one suture anchor (via Mason Allen configuration repair), and utilizing a supplemental internal brace. These techniques also showed no significant difference in the improvement of AOFAS scores or complication rates compared to other standard procedures. Importantly, these findings are strictly relevant to financial cost-efficacy, and each patient should be treated on a case-by-case basis at the surgeon’s discretion. Concomitant injuries may warrant less cost-effective options to address all associated pathology.
Zeng et al. found that arthroscopic surgeries incur higher costs due to increased operating time. The observed difference between operating times was significant (31.7 ± 9.5 min open to 53.8 ± 11.7 min arthroscopic); however, the authors also noted radiofrequency electric knives were an added cost to consider as well. It is important to note that lateral ankle sprains may also occur with concomitant injuries, including osteochondral lesions, peroneal tendon injuries, synovitis, fractures, or deltoid ligament disruption. Many of these injuries are intra-articular and indicate the use of arthroscopic techniques. The value of pre-operative MRI findings may help confirm the chronic ATFL rupture and detect other injuries; however, advanced imaging often results in false-positive, clinically misleading, or irrelevant findings. Considering patient functionality, physical exam findings, and MRI findings collectively in concert, the surgeon’s discretion should help guide whether added arthroscopy is indicated.
The implants utilized directly affect the overall cost of surgery, both in implant cost and implications for surgical technique. Liu et al. utilized a single-suture technique with a Mason-Allen repair configuration, reporting their technique as more cost-effective than traditional two-anchor repair via horizontal mattress suture configuration. The authors found no difference in functional outcomes between both groups; AOFAS scores from the Mason-Allen repair improved (71.3 ± 6.1 to 94.5 ± 1.9) nearly identically to the two-anchor horizontal mattress repair (73.2 ± 7.5 to 95.0 ± 2.2). Despite the equivalence in functional outcomes, the cost of the Mason-Allen technique was significantly lower (21,088.6 ± 2717.5 versus 27,987.2 ± 2230.8 CNY) because of the cost of fewer anchors and shorter operative time. Indeed, the single anchor Mason-Allen repair technique appeared notably faster (27.0 ± 4.7 versus 41.5 ± 5.9 min). A review by Cho et al. further supported these findings, citing that using at least two suture anchors has not significantly affected patient outcomes. While a variety of suture anchors and repair configurations exist, there does not appear to be a functionally superior option. In the spirit of providing cost-effective care for operable CLAI, it appears less is more.
Contrary to these findings, Vanatta et al. found that utilizing an added implant (e.g., an internal brace) resulted in overall cost savings when considering the total cost of care. They reported that while the suture tape internal brace (+ST) added $900 to the overall cost of surgery, it resulted in fewer physical therapy visits, less time off work, and equivalent improvement in functional outcome scores compared to suture anchor repair alone. Similarly, Neary et al. performed a Markov analysis demonstrating while standard MB groups incurred lower direct costs than patients treated with added internal brace ($2318.88 versus $4004.93, respectively), there was an increased length of physical therapy and time to return to pre-injury activity in the standard MB group. Further, they found no difference in quality-adjusted life-year scores (QALY’s). DeVries et al. supported that internal bracing allowed for early ankle mobilization with two to three weeks of reduced time away from work compared to late mobilization strategies. While not all patients necessarily require internal brace augmentation, high-risk athletes, patients desiring quicker return to work, and revision cases should all be considered candidates Table 1 .
Table 1
Inclusion studies.
| Study Names | Procedure Performed | Number of patients per procedure | Number of Male Patients | Mean Age | Follow Up Duration |
|---|---|---|---|---|---|
| Vanatta | MB | 117 | N/A | N/A | 12 months |
| MB + ST | 49 | N/A | N/A | 12 months | |
| Liu | MB+ Mason Allen | 30 | 20 (66.7) | N/A | 36–72 months |
| MB | 34 | 24 (70.5) | N/A | 36–72 months | |
| Zeng | Open MB | 10 | 7 (70.0) | 27.7 ± 9.7 | 36 months |
| Arthroscopic MB | 17 | 15 (88.2) | 30.9 ± 6.0 | 36 months |
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