Ankle Lateral Ligament Augmentation Versus the Modified Broström-Gould Procedure: Response

Author’s Response:

I would like to thank Martinelli et al for their interest in our article and the feedback offered. Our study was a clinical 5-year randomized controlled trial comparing patient-scored outcomes in patients undergoing the modified Broström-Gould (MBG) procedure relative to a ligament augmentation procedure. ⁴ Martinelli et al question the inclusion criteria that we used, suggesting that they were too “vague to objectively assess the instability.” In their letter, they refer to the article by Jung et al. ³ Interestingly, the inclusion criteria used by Jung et al are less precise than those used in our study. For example, the duration of symptoms in their patients varied from 1 to 240 months. The diverse nature of their study population is further suggested by the fact that approximately half of the patients had a MBG procedure performed and the other half, a ligament reconstruction with a semitendinosus allograft. The cited article has a number of other significant weaknesses, including its retrospective nature, reliance on medical records only, and the fact that 50 of the 172 ankles that satisfied the study criteria were not included. Martinelli et al seem to have presumed the accuracy of the magnetic resonance imaging (MRI), even though the authors themselves cautioned that they could not guarantee the interobserver reliability, accuracy, or consistency of the MRI findings, nor could they comment on the correlation with mechanical properties of the ligaments or the intraoperative findings. For these reasons, MRI is not useful as a research tool or for definitive operative planning. The final operative decision can be made only at the time of surgery, dependent on the quality of the tissues available. For similar reason, MRI could not have assisted us to “better stratify” the patients.

Martinelli et al also comment on the weakness of radiological tests, such as stress radiography. We agree with this comment, did not use this in our study, and fail to see the relevance of this comment in relation to our study.

Martinelli et al state that the MBG can restore varus stability but not rotational instability, with no reference to support this comment. The majority of published research has involved the use of the MBG procedure for anterior talofibular ligament injuries, with or without calcaneofibular ligament injury. This pattern of injury results in anterolateral rotatory instability; therefore, the literature would seem to contradict Martinelli et al. They even refer to a sectioning study that supports the predominant role of the anterior talofibular ligament in controlling anterolateral rotatory instability. ² Using similar reasoning, I am confused about the following comments: “Lateral ligament reconstruction techniques, such as the modified Broström-Gould, restore varus instability but could not restore rotational instability, especially in the case of multiple-ligament injuries.”

Martinelli et al also state that some surgeons perform ligament reconstructions for more severe instabilities, using allograft or autograft. The imprecise use of the term “severe instabilities” (ie, are they referring to severe single-ligament injuries, multiple-ligament injuries, complex ankle injuries, etc?) does not support their argument, nor does the fact that some surgeons favor anatomic procedures in certain instances without the support of research in the form of a randomized controlled trial. The meta-analysis that they cite merely documents the marked lack of scientific evidence to support such opinions. ¹

We agree that the incorporation of accurate clinical and radiological parameters would be useful but only if they are practical and have demonstrable reliability, accuracy, and repeatability. Currently this is not the case, and the premature use of such parameters is inaccurate, expensive, and potentially misleading. Like all human clinical research, our article represents a compromise between the perfect study and clinically appropriate, ethical, and practical research.