Interventions for treating chronic ankle instability.
BACKGROUND
Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. The initial form of treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered.


OBJECTIVE
To compare different treatments, both conservative and surgical, for chronic lateral ankle instability.


METHODS
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (to July 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 3), and MEDLINE (1966 to April 2006), EMBASE (1980 to April 2006), CINAHL (1982 to April 2006) and reference lists of articles.


METHODS
All randomised and quasi-randomised controlled trials of interventions for chronic lateral ankle instability were included.


METHODS
Two review authors independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled.


RESULTS
Seven randomised trials were included and divided into three groups: surgical interventions; rehabilitation programs after surgical interventions; and conservative interventions. None of the studies were methodologically flawless. Only one study described an adequate randomisation procedure. Only two studies, both about rehabilitation programs after surgery, had a moderate risk of bias; all other studies had a high risk of bias. Due to clinical and methodological diversity, extensive pooling of the data was not possible. Surgical interventions (four studies): one study showed more complications after the Chrisman-Snook procedure compared to an anatomical reconstruction, whereas another study showed greater mean talar tilt after an anatomical reconstruction. Subjective instability and hindfoot inversion was greater after a dynamic than after a static tenodesis in a third study. The fourth study showed that the operating time for anatomical reconstructions was shorter for the reinsertion technique than for the imbrication method. Rehabilitation after surgical interventions (two studies): both studies provided evidence that early functional mobilization leads to an earlier return to work and sports than immobilisation. Conservative interventions: the only study in this group showed better proprioception and functional outcome with the bi-directional than with the uni-directional pedal technique on a cyclo-ergometer.


CONCLUSIONS
In view of the low quality methodology of almost all the studies, this review does not provide sufficient evidence to support any specific surgical or conservative intervention for chronic ankle instability. However, after surgical reconstruction, early functional rehabilitation was shown to be superior to six weeks immobilisation regarding time to return to work and sports.
de Vries
J S
JS
Orthotrauma Research Center Amsterdam (ORCA) Academic Medical Center, Orthopaedic Surgery, Meibergdreef 9, PO Box 22660, Amsterdam, Noord-Holland, Netherlands. j.s.devries@amc.uva.nl
Krips
R
R
Sierevelt
I N
IN
Blankevoort
L
L
D000843:Ankle Joint / Q000601:surgery; D002908:Chronic Disease; D006801:Humans; D007593:Joint Instability / Q000209:etiology / Q000601:surgery / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic; D013180:Sprains and Strains / Q000150:complications