Surgical vs Conservative Treatment for Acute Ankle Sprains: Background

Surgical vs Conservative Treatment for Acute Ankle Sprains: Background

Main Outcome Measures

The primary outcome measures of the review were return to preinjury activity (sport or work), recurrence, persistent pain and subjective instability (giving way). The secondary outcome measures were objective instability (talar tilt, anterior drawer measures), swelling, stiffness, ankle mobility, muscle atrophy, complications and satisfaction.

Results

Twenty studies (n=2562 participants) were included in the review, although it is noted that only 12 studies (57% of participants) reported data that could be pooled. The publication dates span the period from 1965 to 2006. The participants in the included studies were mostly young adult (median about 25 years), active men (55–100%).

Several of the primary outcomes show pooled effects in favour of surgical interventions (point estimate of RR between 0.57 and 0.80). However, in all analyses the effect size is heavily influenced by one low-quality study from 1978 that shows striking effects in favour of surgery. When appropriate analyses are conducted to account for the statistical heterogeneity caused by this study (random effects model) or it is excluded from the analysis, there is no longer any difference between the surgical and conservative conditions for any of the outcomes. The results for long-term pain shown in figure 1 are typical of those for all the primary outcomes.

With respect to the secondary outcomes the pattern is very similar, although the results suggest a possible positive effect of surgery on objectively measured instability (radiographical assessment of talar tilt or anterior drawer test). Different types of conservative treatment were not shown to influence the differential effect. In the studies that measured complications, these were generally higher in the surgical group, although it should be noted that some complications are clearly not applicable to both groups, for example scar tenderness and wound infection.

Clinical Implications

Current best evidence does not endorse the choice of surgical over conservative treatment (or vice versa) following acute ankle sprain. It should be noted though that surgical interventions are usually followed by a period of rehabilitation, similar to that tested in the 'conservative' arms of the included studies. As such this review could be said to investigate the question of whether adding surgery to conservative management confers any benefit. It appears at this stage that both treatment regimens result in similar effects on important outcomes for this population; that is, no evidence of the superiority of one intervention over the other. Importantly, the results of this review are not generalisable to people with chronic ankle problems who have failed to respond to previous treatment.