Comparison of Inferior Extensor Retinacular Reinforcement Versus Nonreinforcement in Arthroscopic Isolated Anterior Talofibular Ligament Repair for Chronic Lateral Ankle Instability: A Systematic Review and Meta-analysis

Background: Approximately 20% of acute ankle sprains progress to chronic lateral ankle instability (CLAI), requiring surgical intervention. When only the anterior talofibular ligament (ATFL) is ruptured, it is controversial whether to perform arthroscopic inferior extensor retinacular (IER) reinforcement. Purpose: To assess the postoperative outcomes of IER reinforcement versus nonreinforcement in arthroscopic treatment of CLAI with ATFL-only injury. Study Design: Systematic review; Level of evidence, 3. Methods: Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the PubMed, Cochrane Library, Embase, and Web of Science databases were searched for publications on arthroscopic ATFL repair with versus without IER reinforcement. The final search date was July 7, 2023. Through a comprehensive meta-analysis, functional outcomes (American Orthopaedic Foot & Ankle Society Ankle-Hindfoot [AOFAS], Karlsson-Peterson [K-P], and Foot and Ankle Outcome Score [FAOS] scores), radiological outcomes (talar anterior translation and talar tilt), and complication rates (superficial peroneal nerve injury, knot irritation, and total complications) were evaluated. The mean difference (MD) was compared for continuous outcomes, and the odds ratios (ORs) were compared for categorical outcomes between the patients with versus without IER reinforcement. Results: A total of 4 studies (n = 271 patients; 157 male, 114 female; 141 patients with IER reinforcement, 130 without IER reinforcement) were included in the final analysis. There were no significant differences between the patients with versus without reinforcement regarding AOFAS score (MD = 0.72 [95% CI, –2.17 to 3.61]; P = .63; I 2 = 0%), any of the FAOS subscores, talar anterior translation (MD = 0.10 [95% CI, –0.53 to 0.73]; P = .76; I 2 = 0%), talar tilt (MD = 0.14 [95% CI, –0.86 to 1.13]; P = .79; I 2 = 0%), or total complications (OR = 2.29 [95% CI, 0.92 to 5.71]; P = .07; I 2 = 24%). However, the IER reinforcement group showed superior postoperative K-P scores compared with the nonreinforcement group (MD = 6.22 [95% CI, 2.17 to 10.26]; P = .003; I 2 = 0%). Conclusion: The results of the meta-analysis suggest that IER reinforcement may not be necessary for achieving satisfactory postoperative outcomes in CLAI with ATFL-only injury. Further research is required to investigate the impact of ligament injury severity, body weight, and concomitant calcaneofibular ligament injuries on the results. Registration: CRD42023447669 (PROSPERO).