To the editor:
We read with interest the article entitled " Treatment of Ruptures of the Lateral Ankle Ligaments : A Meta-Analysis " (82-A: 761-773, June 2000), by Pijnenburg, Van Dijk, Bossuyt, and Marti. The authors conclude : " A no-treatment strategy for ruptures of the lateral ankle ligaments leads to more residual symptoms. Operative treatment leads to better results than functional treatment (...) ". This statement is in conflict with the previous meta-analyse about this subject published in the Journal by Kannus and Renström (2) which concluded that functional treatment is better. Further more, as we will show, no important randomized study has been published subsequently which agrees with the conclusions of Pijnenburg et al.(4) Our purpose in writing is to try to analyze how they found arguments for surgery in ankle ligament ruptures.
In Fig. 2-A and 2-B they compare residual symptoms (pain and giving-way) after operative treatment or functional treatment. Their conclusion in favor of sugery directly results of these Figures . We meticulously reviewd the cited studies from these Figures and make the following observations.
Five of the seven studies in Fig. 2-B include indeed a cast-treatment of at least three weeks. According to Pijnenburg et al.(4) , " a short period of cast immobilization (up to three weeks) was also considered to be a form of functional treatment ". The study of Korkala et al.(3) includes a plaster cast for four weeks, which is in conflict with their own definition of the functional treatment. Nevertheless this study is used in both Fig. 2-A and 2-B.
1.The usual definition of "functional treatment " includes taping, strapping or commercially available ankle brace, allowing an early controlled mobilization of the ankle joint and an early weight-bearing. This definition is used by Kannus and Renström (2) and is found in all important studies published after his meta-analyse. Those by Povacz et al.(5), Zwipp et al.(7) and Kaikkonen et al. (1) are the most interesting in this present discussion. Zwipp et al(7) allows " three to five days in split lower leg cast " that still permits an early mobilization. Kannus and Renström (2) considers the group of patients treated by a plaster cast as separate group from the one treated by functional methods. His conclusion in favor of functional treatment does not include patients treated by a plaster cast. A plaster cast for three or four weeks should clearly not be considered as a " functional treatment ".
2- The only cited study which compares functional treatment (as usually defined) with surgery is the one of Kaikkonen et al.(1). We also found an article written by Zwipp et.al(7). Although it is mentioned in Table I we do not understand why it is not shown in Fig. 2-A and 2-B. This study includes two groups of patients treated by operative treatment (respectively followed by cast immobilization and early functional treatment) and two groups treated by consevative treatment (respectively cast immobilization and early functional treatment). Both Kaikkonen et al. (1) and Zwipp et al.(7)describe functional treatment as the method of choice.
3- The largest study in favor of the operative treatment is the thesis of Van der Ent (6). It remains unpublished in the international literature and has not been included in the meta-analyse by Kannus and al.2 This thesis concerns 357 patients and widely contributes to the total of 914 patients of the Fig. 2-B.
4- The article written by Povacz et al.(5) is mentioned in Table I as a comparaison of an operation + Aircast for six weeks versus Aircast six weeks. In Fig. 4-A and 4-B it is considered as a comparaison between operative treatment + cast six weeks versus a cast for six weeks. This article is in fact a comparison of an operative treatment + cast for six weeks versus conservative treatment with elastic wrapping followed by an ankle brace (Aircast, Summit, NewJersey) for six weeks. So, neither Table 1 nor Fig. 4-A and 4-B correcly refer to the study of Povacz et al.(5). Its proper place could be in Fig. 2-A and 2-B (" operative treatment versus functional treatment "). Once again Povacz et al.(5) recommends the functional treatment contrary to most of the other studies of these two figures.
Considering the above mentionned comments, the conclusion of the meta-analyse by Pijnenburg et al.(4) should be interpreted cautiously.
References
1. A. Kaikkonen, P. Kannus, and M. Järvinen
Surgery versus functional treatment in ankle ligament tears. A prospective study :
Clinical Orthopaedics and Related Research, 326 : 194-202, 1996
2. P. Kannus , and P. Renström
Current concepts review. Treatment for acute tears of the lateral ligaments of the ankle. Operation cast or early controlled mobilization :
The Journal of Bone and Joints Surgery, 73-A : 305-312, 1991
3. : O. Korkala, M. Rusanen, P. Jokipii, J. Kytömaa, and V. Avikainen
A prospective study of the treatment of severe tears of the lateral ligament of the ankle :
International Orthopaedics, 11 : 13-17, 1987
4. A.C.M. Pijnenburg, C.N. Van Dijk, P.M.M. Bossuyt, and R.K. Marti
Treatment of Ruptures of the Lateral Ankle Ligaments : A Meta-Analysis :
The Journal of Bone and Joints Surgery, 82-A : 761-773, 2000
5. P. Povacz, F. Unger, K. Miller, R. Tockner, and H. Resch
A randomized, prospective study of operative and non-operative treatment of injuries of the fibular collateral ligaments of the ankle :
The Journal of Bone and Joints Surgery, 80-A : 345-351, 1998
6. F. Van Der Ent
Lateral ankle ligament injury. Thesis, Erasmus Universiteit, Rotterdam, 1984
7. H. Zwipp, R.Hoffmann, H. Thermann, and B.W. Wippermann :
Rupture of the ankle ligaments :
International Orthopaedics, 15 : 245-249, 1991
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