A Comparative Analysis of Complication Rates in Arthroscopic Repair of the Lateral Ankle Ligament and the Brostrom-Gould Technique: A Systematic Review

Injury to the lateral ligament is the most common cause of chronic lateral ankle instability. Lateral ankle instability is usually managed through conservative management, but surgery is indicated if this fails to relieve the symptoms. Surgical repair of the lateral ligament involves many surgical techniques including the arthroscopic repair technique and the modified Brostrom-Gould technique. Due to the minimal research on the complication rates of both techniques, this systematic review aims to establish the complication rates. To obtain articles, a detailed systematic search of MEDLINE, PubMed, Embase, Web of Science, and Cochrane Library was performed. The articles found using the keywords “arthroscopic,” “Brostrom,” and “Brostrom-Gould” were reviewed by two independent authors. The authors then selected the articles according to our predetermined eligibility criteria. The articles that met our inclusion were then chosen for data extraction. Specific details obtained from the study included the author’s details, the setting of the study, and the complications of the study. The online search yielded 975 articles, but only 44 met our inclusion criteria and were included in the review. The total sample size for the review was 2041 patients, the modified Brostrom technique was performed on 760 patients while on the remaining 1281 patients, arthroscopic repair was performed. On the characteristics of the sample, the age of the samples ranged from eight years to 83 years, while the mean BMI ranged from 21.0 kg/m² to 25.3 kg/m². The various complication rates included superficial peroneal nerve injury (2.3% in arthroscopic Brostrom and 0.65% in the Brostrom-Gould), wound infections (1.3% in arthroscopic Brostrom and 1.8% in the Brostrom-Gould), persistent pain (1.5% in the arthroscopic Brostrom and 1.1% in the Brostrom-Gould), and lastly recurrent instability (0.31% in arthroscopic Brostrom and 3.0% in the Brostrom-Gould). Overall, the complication rates of the arthroscopic repair were 11.00%, while those of the modified Brostrom-Gould were 10.65%. The study demonstrated that although the arthroscopic technique had higher complication rates than the modified Brostrom technique, the difference was insignificant. Therefore, we concluded that surgeons performing the arthroscopic Brostrom technique should have good arthroscopic skills to minimize complications.


Introduction And Background
Inversion stress to the foot and ankle is a common musculoskeletal injury, especially in athletes who are competing in various levels of sports.The ligaments most frequently damaged are the lateral ankle ligaments, specifically the calcaneofibular ligament and the anterior talofibular ligament [1].These injuries are among the common causes of ankle instability in athletes.Evidence from research indicates that the rate at which it occurs in both men and women is almost equal [2].The resulting chronic ankle instability can be classified into mechanical and functional instability.Functional instability is subjective according to the patient and is captured during history taking, while mechanical instability is objective and captured by the clinician during a physical exam [3].
The treatment modalities for chronic ankle instability include conservative management and physical therapy, and failure of both indicates surgery [3].Conservative management is recommended in patients with symptoms for at least two months [3].Conservative management involves the standard RICE (rest, ice, compression, and elevation) principles used to manage soft tissue injuries.Additionally, lateral heel wedges, proprioceptive training, peroneal strengthening, bracing and strapping, and lateral heel wedges are among the modalities used in ankle rehabilitation.Achilles tendon stretching and lateral heel wedges prevent hindfoot malpositioning, frequently leaving the lateral ligaments prone to injury [4].On the other hand, peroneal strengthening and proprioceptive training stabilize the ankle and the hindfoot by improving the maintenance of ankle position when external forces are applied [4][5][6].Ankle braces compensate for the instability, but those that provide clinically adequate stability tend to be bulky; hence, they are not routinely used [7].Rehabilitation exercise forms a critical part of conservative management.They are continued for at least two to three months [8].
Surgery is usually carried out when conservative management fails to provide symptomatic relief.Surgical management is recommended after the patients have not improved after a three to six-month conservative management trial [9].Various surgical techniques are used to manage chronic instability of the ankle.The methods range from simple repairs to complex reconstructions.The repairs include reattaching or shortening (imbricating) the damaged tissue.Reconstructions, on the other hand, include the replacement of ligaments with graft tissue, either allograft or autologous graft [9].The reconstructive surgical techniques have evolved from the non-anatomical ones, e.g., Watson-Jones, Castaing, and Snook procedures, to the anatomical ones.Such developments have been due to possible complications of future ankle degeneration due to the non-anatomical forces associated with the non-anatomical techniques.Brostrom proposed the Brostrom technique in 1966 to avoid muscle imbalance by repairing the anterior talofibular ligament (ATLF) using the remnants [10].Gould further modified this technique in 1980 by reinforcing the extensor retinaculum.
The modified Brostrom-Gould technique is primarily indicated for chronic, recurrent, lateral ankle instability.The method is only performed after the clients have undergone an entire course of physical therapy and failed to improve their symptoms [11].Preoperative radiological imaging includes magnetic resonance imaging (MRI), which aids in assessing occult pathologies, including peroneal tendon and osteochondral pathologies.Additionally, a computed tomography (CT) scan can be done to get a complete evaluation of the pathology [12].
Hawkins pioneered the arthroscopic technique, which involved repairing the lateral ankle ligament with his stapling approach [13].The method required two additional portals and ablation of the lateral surface before ligament plication with a staple.The series of 24 patients treated with the process had few complications.These complications were due to the placement of the staple.Kashuk et al. (1994) later developed a suture anchor technique that avoided the difficulties caused by prominent staples [14].They used an additional accessory anterolateral portal to place suture anchors in the talus or the fibula [14].Corte-Real and Moreira (2009) later attempted to develop a more reliable arthroscopic ligament repair.Their technique required an accessory anterolateral portal and used only one anchor.The technique had encouraging results as it had only two recurrences.However, the multiple suture passes contributed to slightly increased superficial peroneal nerve (SPN) injury (n = 3) [15].In 2007, in potentially trying to avoid SPN injury, Acevedo and Mangeno (2015) started using another technique in which they tried to simplify all the prior methods.They used only two standard anterior portals.The technique allowed the placement of two individual suture anchors, which were believed to improve pull-out strengths and stability.Separate passes of sutures engaged a wider surface area, and Acevedo and Mangeno (2015) believed that this potentially avoided potential injury to the SPN [11].
The Brostrom-Gould technique and arthroscopic repair are the two main techniques used to repair lateral ankle injuries.Both techniques have shown effectiveness in restoring ankle stability.However, it is essential to understand the relative safety and occurrence of complications associated with each technique.The complications of the arthroscopic technique include SPN injury, recurrent instability, and unidentified pathology that continues to limit function and cause symptoms [12].Additionally, the complications of the arthroscopic technique include persistent pain symptoms and postoperative neuritis.The complications' treatment included removing sutures that had trapped the SPN to treat the postoperative neuritis [11].The postoperative neuritis was self-limiting for other patients, while others had chronic mild postoperative neuritis [11].The complications of the Brostrom-Gould technique include persistent ankle pain laterally, subtalar laxity when the ankle is dorsiflexed, and wound complications a few weeks postoperatively.Oral antibiotics can treat the complications, or if the infection is severe, surgical debridement may need to be carried out [16].
Based on our knowledge, this is the first systematic review to directly analyze the complication rates of the Brostrom and Gould technique.The primary objective of this study is to compare the complication rates in patients undergoing arthroscopic repair of the lateral ankle ligament and the modified Brostrom-Gould technique.Specifically, the research aims to evaluate the overall complication rates associated with each technique; assess specific complications such as infection, wound healing issues, nerve damage, blood vessel injury, persistent pain, joint stiffness, and the need for additional surgeries; identify potential factors that may contribute to variations in complication rates between the two techniques; and lastly, establish various ways the complications are managed and if there are permanent sequelae of the various techniques.

Study Design
The search terms were combined using Boolean operators "AND," "OR," and "NOT."

TABLE 1: Search terms
After the eligible studies were obtained, the authors implemented the second strategy.This strategy involved manually searching the lists of references for other eligible studies that had not been identified through the electronic search.This enabled the authors to obtain all the possible articles.Any discrepancies were resolved through discussion by the reviewers and a third reviewer.

Quality Appraisal
Two independent reviewers evaluated the quality of the studies using the Newcastle-Ottawa quality assessment scale (NOS).A study was graded good quality if it had a total rating of 6 or more, fair quality if it had a 3 to 5 rating, and poor quality if it had a 2 or less rating.The results are shown in Table 2.

Data Extraction and Evaluated Outcomes
The articles that met the inclusion criteria were independently reviewed by two reviewers.The reviewers obtained the relevant data for review.The specific data that were collected from each study included the first author's maiden name and publication year, the study design, the characteristics of the participants (mean age and mean BMI), the type of surgical technique used, the sample size, the mean follow-up period, and the primary outcomes.The primary outcomes included were the complications of the various techniques used.

Results
The online search conducted through various electronic databases stated earlier yielded 975 articles.After careful analysis of these articles, 424 duplicates were identified, which the reviewer excluded from the study.The reviewers then screened the remaining 551 articles' abstracts and titles; all 551 met the screening criteria, and the reviewers could not retrieve 415 articles.The remaining 139 were now screened using the pre-determined eligibility criteria.After the assessment, 40 articles were excluded because they were not published in English, 48 articles were reviews and meta-analyses, hence excluded, and two others were excluded because they were letters to the editor.The final articles to be included were 44, which met all our inclusion criteria.The results of the search are shown using the PRISMA flow diagram (Figure 1).Various surgical techniques were used in the studies, including the arthroscopic Brostrom technique and the modified Brostrom-Gould technique.Only the results of the complication rates of the arthroscopic Brostrom technique and modified Brostrom-Gould technique were included in comparative studies where various methods were used in lateral ankle repair.The study's total patient sample had 2041 patients; 760 patients underwent the modified Brostrom-Gould procedure, while the remaining 1281 patients underwent arthroscopic Brostrom repair.The complication rates varied from no complication rates in some case studies and case reports to as high as 27% complication rates in some studies.The complications of the various techniques included superficial wound infection, SPN and sural nerve injuries, knot pain, recurrent instability of the ankles, persistent pain, neuromas, and suture knot granulomas, among others.The various complication rates for the two techniques are displayed in Table 3.

Discussion
This systematic review discussed the complication rates of various studies on the arthroscopic Brostrom technique and the modified Brostrom-Gould The most important finding in the arthroscopic Brostrom technique was that complication rates ranged from 0% in some studies to 29% in other studies [15,51,52].For the modified Brostrom-Gould technique, on the other hand, the complication rates ranged from 0% complication rates in some studies to 30% complication rates in others [38,48].The absolute mean complication rate of the studies reviewed for the modified Brostrom-Gould procedure is 10.65%, while the one for the arthroscopic repair is 11.00%.The complication rates in the arthroscopic Brostrom repair were higher than those of modified Brostrom-Gould but not significantly.These results are similar to those of a systematic review by Brown et al. (2018), who reported higher complication rates in the arthroscopic Brostrom technique (11.5%) compared to 5.4% in the Brostrom-Gould technique [58].Additionally, the rates of complications of arthroscopic Brostrom procedure are similar in both reviews.However, the rates of complication in the modified Brostrom-Gould technique in our systematic review (10.65%) are slightly higher compared to those of Brown et al. (2018) (5.4%), and this may be attributed to our large sample size, which improved the statistical ability of our review [58].
Regarding specific complications, cases of SPN injury and neuritis were reported among various studies and across all the techniques.The rate of SPN injury in modified Brostrom techniques was minimal at a rate of 0.65%, while that of the arthroscopic Brostrom repair was higher with the rate of SPN injury at 2.3% of the sample of patient's studies.The higher complication rates of SPN injury associated with the arthroscopic Brostrom technique are similar to those reported by Wang et al. (2014), who reported that SPN injuries are frequently reported complication in the studies they reviewed [59].To aid in minimizing this risk, Acevedo and Mangone (2015) further recommended that the orthopedic surgeons performing the procedure must possess a profound knowledge of the ankle and foot anatomy and have excellent arthroscopic skills [11].Vega et al. (2013) further add that surgeons should be cautious when creating portals, inserting the instruments, and carrying out the procedure, as this minimizes the risk of nerve injuries [60].
Infectious complications postoperatively are common.In both groups, wound infection and healing difficulties were reported.The rates of infectious complications in the arthroscopic group were 1.3%, while those in the modified Brostrom group were 1.8%.Most infections were self-limiting, while others had to be treated with antibiotics.The pathogens observed to cause the infections included pseudomonas and Peptostreptococcus species, seen in wound cultures [16].The treatment regimen consisted of clindamycin or cephalexin.In severe cases, some wounds had to undergo irrigation and surgical debridement.All the cases of wound infection reported were successfully managed, and residual infection existed.
The arthroscopic repair was initially developed as a minimally invasive procedure, and its use has become popular as it reduces recovery pain and postoperative pain.Another complication reported was postsurgical pain.The pain ranged from one caused by nerve irritation to another caused by knot irritation.The rates of surgical pain caused included 1.1% in the Brostrom-Gould group and 1.5% in the arthroscopic Brostrom technique.Some of the pain was self-limiting and subsided on its own, some were treated with nonsteroidal anti-inflammatory drugs while other types became recurrent and persistent [40].
Other complications were recurrent instabilities after the procedures.The rate of recurrent instability was lower in the arthroscopic Brostrom repair (0.31%) compared to the modified Brostrom-Gould technique (3.0%).The rate of recurrent instability of the modified Brostrom technique is less than that reported by Lewis et al. (2021), i.e., 9.28% [61].The authors attributed these phenomena to the patients resuming their activities, as most of the injuries were a result of postoperative injuries.The patients were placed on conservative management without the need for revision surgery [28].Additionally, Zhou et al.
(2021) recommended that they wear ankle pads during exercises for additional protection.The instability did not provide a significant disturbance in their activities of daily living [40].

Limitations of the study
One of the limitations of this study is that some of the included studies have small sample sizes.The drawback contributed to the small sample size for the specific complications of the various techniques.
Although our sample size and included studies are slightly larger than the one for other systematic reviews, the specific sample sizes of the various individual complications were limited, and we would recommend that future studies focus on the specific complications and assess their rates for each of the procedures.Another limitation was on the characteristics of the included populations; hence, we could obtain only the mean age for the various studies.This reduced our ability to relate the complication rates to the sample populations' various characteristics.

Conclusions
This systematic review established that the rate of complications is higher in the arthroscopic repair compared to the modified Brostrom-Gould procedure.The wound infection rate was, however, higher in the modified Brostrom-Gould group than in the arthroscopic group.The rate of injuries to the SPN was higher in the arthroscopic group compared to the Brostrom-Gould group; hence, we recommended that caution be observed by surgeons who are operating and also the surgeons who possess good arthroscopic skills before performing the procedure.In summary, the difference between the complications of the Brostrom-Gould and arthroscopic repair procedures was insignificant; hence, we can conclude that both procedures are productive in avoiding complications.We recommend that future systematic reviews be conducted to compare the two techniques regarding specific complications.

FIGURE 1 :
FIGURE 1: PRISMA flow diagram PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

TABLE 2 : Quality assessment outcomes of the included studies
AHRQ: Agency for Healthcare Research and Quality.

TABLE 3 : The complication rates of the two surgical techniques
The characteristics of the various studies have been displayed in Table4.

TABLE 4 :
Study characteristics AB: arthroscopic Brostrom-Gould technique; OB: open Broström-Gould technique; AS group: arthroscopic Broström-Gould repair group; SPN: superficial peroneal nerve; AOFAS: American Orthopaedic Foot and Ankle Society.The characteristics of the sample populations included the mean age and mean body mass index (BMI) where one was provided.The minimum age in the included studies was eight years, and the maximum age was 83 years.The mean BMI ranged from 21.0 kg/m² to 25.3 kg/m².One study provided the mean weight, which was 69.9 kg.The mean BMI ranged from 21.0 kg/m² to 25.3 kg/m².