Surgical therapy vs conservative therapy for patients with acute injury of lateral ankle ligament: A meta‐analysis and systematic review (2024)

Keywords: conservative treatment, lateral ankle ligament, meta‐analysis, surgical

2.1. Search strategy

The following electronic databases were searched to identify eligible studies updated to January 2018 on conservative therapy vs surgical therapy for acute injury of the lateral ankle ligament: PubMed, The Cochrane Library, and Embase. In addition, literature or publications that were related to this meta‐analysis were identified as well. The literature research process was performed by two reviewers independently. Any differences were settled by discussion with a third reviewer to reach consensus.

2.2. Study selection

The inclusion criteria were as follows: (a) randomised controlled trials or comparative studies; (b) the study patients had no other serious concurrent disease; (c) the surgery group was treated using ligament repair or reconstruction; and (d) the conservative therapy group were treated using plaster fixation, bandage fixation, ankle support, and functional treatment.

The exclusion criteria were as follows: (a) duplicate publications or duplicate contents and results; (b) meta‐analysis, conference report, theoretical research, economic analysis, expert comment, systematic review, and case report; and (c) irrelevant outcomes.

2.3. Data extraction and quality assessment

The search process for all the included studies was performed to determine the above‐mentioned criteria by two reviewers independently. Any differences were settled by discussion with a third reviewer. Data were extracted from all the included studies in two parts: the main outcomes and basic information. The name of the first author, year of publication, study design, country, details of therapy, sample size, and Jadad score were included in the first part. The following clinical outcomes were obtained from the second part: recurrent ankle injury, limited range of motion, ankylosis, deep vein thrombosis (DVT), scar tenderness, sensory loss, necrosis or wound infection, complications, the AOFAS score, and effective rate. The Jadad score checklist was used to appraise the quality of the included studies. We evaluated all the randomised controlled trial (RCTs) in five aspects: appropriateness of generating randomised sequence, randomisation statement, use of double blind, description of double‐blinding methods, and details of withdrawals and dropouts. Studies with a score of less than 3 represented low quality and high bias risks, studies with a score > 3 were indicated to be a high‐quality trial. The above‐mentioned process for all the included studies was performed by two reviewers independently. Any differences were settled by discussion with a third reviewer to reach an agreement.

2.4. Statistics Analysis

Statistical analysis of all the included studies was performed using STATA 10.0 (StataCorp, College Station, Texas). The heterogeneity of clinical trial results was assessed by χ² and I² tests to determine the model of analysis (the random‐effects model or the fixed‐effects model). Heterogeneity was considered to be high if the χ² test P‐value was less than 0.05 and I² test value was larger than 50%, and the random‐effects model was used. Heterogeneity data were considered to be acceptable if the χ² test P‐value was larger than 0.05 and I² test value was less than 50%, and the fixed‐effects model was used. Continuous variables were expressed as mean ± SD and analysed by mean difference (MD). Categorical data were presented as percentages and analysed by relative risk (RR) or odds ratio (OR). Recurrent ankle injury, limited range of motion, ankylosis, DVT, scar tenderness, wound infection or necrosis, sensory loss, complications, and effective rate were analysed by RR and 95% confidence interval (CI). The AOFAS score was analysed by MD and 95% CI.

3.1. Study characteristics

A total of 819 articles were identified through search using the indexes. During a brief screening of abstracts and titles, 761 articles were excluded from the current study, leaving 58 articles to be further evaluated. During full‐text screening, 45 articles failed to meet the following criteria: no eligible groups (8), nonblack of clinical outcomes (19), or theoretical research (18). Finally, 13 studies10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 were included in this meta‐analysis, with 834 patients in the surgery group and 930 patients in the conservative therapy group. The overall selection process is shown in Figure 1.

Table 1 summarises the main characteristics of the included studies. The current studies included 16 case‐control groups in 13 studies, RCTs in 10 studies, and retrospective comparative study in 2 studies. The countries of origin included the United Kingdom, Germany, Finland, Denmark, the Netherlands, Australia, Italy, and China in the studies. The main Jadad score was 4.9, which represented high quality of the included RCTs.

3.2. Recurrent ankle injury

Six studies with six case‐control groups provided data on recurrent ankle injury. Based on the I² test value (I² = 61.8%) and χ² test P‐value (P = 0.022), we chose the random‐effects model to analyse recurrent ankle injury. The pooled results showed no significant difference in the incidence of recurrent ankle injury between the two study groups (RR: 1.01, 95% CI: 0.62‐1.65, Figure 2).

3.3. Complications

Twelve studies with 15 case‐control groups provided data on complications. Based on the I² test value (I² = 0.0%) and χ² test P‐value (P = 0.969), we chose the fixed effects model to analyse the complications. The pooled results showed significantly higher rates of complications in the surgery group than the conservative treatment group (RR: 3.31, 95% CI: 2.55‐4.28, Figure 3).

The complications included limited range of motion, ankylosis, DVT, scar tenderness, necrosis or wound infection, and sensory loss. In the subgroup analysis, six studies with nine case‐control groups provided data on limited range of motion. Based on the I² test value (I² = 0.0%) and χ² test P‐value (P = 0.766), we chose the fixed‐effects model to analyse the limited range of motion. The pooled results showed no significant difference in limited range of motion between the two study groups (RR: 1.44, 95% CI: 0.83‐2.50, Figure 4). Four studies with seven case‐control groups provided data on ankylosis. Based on the I² test value (I² = 0.0%) and χ² test P‐value (P = 0.677), we chose the fixed‐effects model to analyse ankylosis. The pooled results showed that the incidence of ankylosis was significantly higher in the surgery group in comparison with the conservative therapy group (RR: 3.63, 95% CI: 2.16‐6.08, Figure 4). Five studies with eight case‐control groups provided data on DVT. Based on the I² test value (I² = 0.0%) and χ² test P‐value (P = 0.953), we chose the fixed‐effects model to analyse DVT. The pooled results showed no significant difference in the incidence of DVT between the two study groups (RR: 1.33, 95% CI: 0.73‐2.41, Figure 4). Six studies with nine case‐control groups provided data on scar tenderness. Based on the I² test value (I² = 0.0%) and χ² test P‐value (P = 0.981), we chose the fixed‐effects model to analyse scar tenderness. The pooled results showed that the incidence of scar tenderness was significantly higher in the surgery group compared with the conservative therapy group (RR: 10.16, 95% CI: 3.89‐26.52, Figure 4). Six studies with nine case‐control groups provided data on sensory loss. Based on the I² test value (I² = 0.0%) and the χ² test P‐value (P = 0.906), we chose the fixed‐effects model to analyse sensory loss. The pooled results showed that the incidence of sensory loss was significantly higher in the surgery group compared with the conservative therapy group (RR: 5.66, 95% CI: 2.76‐11.59, Figure 4). Two studies with two case‐control groups provided data on wound infection or necrosis. Based on the I² test value (I² = 0.0%) and χ² test P‐value (P = 0.817), we chose the fixed‐effects model to analyse the incidence of necrosis or wound infection. The pooled results showed no significant difference in the incidence of wound infection or necrosis between the two study groups (RR: 3.99, 95% CI: 0.45‐35.34, Figure 4).

3.4. AOFAS score

Three studies with six case‐control groups provided data on AOFAS scores. Based on the I² test value (I² = 97.8%) and χ² test P‐value (P = 0.000), we chose the random‐effects model to analyse AOFAS scores. The pooled results showed that, compared with the conservative treatment, surgical treatment significantly increased the AOFAS score (weighted mean difference: 10.33, 95% CI: 6.83‐13.83, Figure 5).

3.5. Effective rate

Three studies with six case‐control groups provided data on the effective rate. Based on the I² test value (I² = 65.0%) and χ² test P‐value (P = 0.014), we chose the random‐effects model to analyse the effective rate. The pooled results showed that the effective rate was significantly higher in the surgery group in comparison with the conservative therapy group (RR: 1.15, 95% CI: 1.04‐1.28, Figure 6).

3.6. Quality assessment and potential bias

In the meta‐analysis, 13 articles were included according to the inclusion and exclusion criteria. The assessment of quality and potential bias were accessed by funnel plot, Egger's test, Begg's, and Mazumdar's rank test. The funnel plot for log RR in complications of the included studies was notably symmetrical, suggesting significant publication bias (Figure 7). Moreover, we detected significant asymmetry using Begg's and Mazumdar's rank test (Z = 1.98, P = 0.048). However, Egger's test result showed significant publication bias (P = 0.032).

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