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Surgical Versus Functional Treatment for Acute Ruptures of the Lateral Ligament Complex of the Ankle in Young MenA Randomized Controlled Trial
Harri Pihlajamäki, MD, PhD1; Kalevi Hietaniemi, MD, PhD2; Mika Paavola, MD, PhD3; Tuomo Visuri, MD, PhD1; Ville M. Mattila, MD, PhD4
1 Research Department, Centre for Military Medicine, P.O. Box 50, FIN-00301, Helsinki, Finland. E-mail address for H. Pihlajamäki: Harri.Pihlajamaki@helsinki.fi. E-mail address for T. Visuri: TuomoVisuri@helsinki.fi
2 Department of Orthopaedics and Traumatology, Helsinki University Hospital, Jorvi Hospital, Turuntie 150, FIN-02740 Espoo, Finland. E-mail address: kalevi.hietaniemi@hus.fi
3 Department of Orthopaedics and Traumatology, Helsinki University Hospital, Töölö Hospital, Topeliuksenkatu 5, Helsinki 00029 HUS, Finland. E-mail address: mika. paavola@hus.fi
4 Department of Orthopaedics, Tampere University Hospital, 33100 Tampere Finland. E-mail address: Ville.Mattila@uta.fi
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Centre for Military Medicine and the Department of Orthopaedic Surgery, Central Military Hospital, Helsinki, Finland

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Oct 20;92(14):2367-2374. doi: 10.2106/JBJS.I.01176
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Some have recommended surgical treatment of Grade-III lateral ligament injuries in very active individuals with high functional demands on the ankle. The purpose of this study was to establish whether surgery provides better long-term results than functional treatment for acute ruptures of the lateral ligaments of the ankle.


Physically active Finnish men (mean age, 20.4 years) with an acute Grade-III lateral ligament rupture of the ankle were randomly allocated to surgical (n = 25) or functional (n = 26) treatment. Ligament injury was confirmed with stress radiographs. Surgical treatment comprised suture repair of the injured ligament(s) within the first week after injury. A below-the-knee plaster cast was worn for six weeks with full weight-bearing. Functional treatment consisted of the use of an Aircast ankle brace for three weeks. The main outcome measures included final follow-up examinations, calculation of an ankle score, stress radiographs, and magnetic resonance imaging scans.


Fifteen (60%) of twenty-five surgically treated patients and eighteen (69%) of twenty-six functionally treated patients returned for long-term follow-up (mean duration, fourteen years). All patients in both groups had recovered their preinjury activity level and reported that they could walk and run normally. The prevalence of reinjury was one of fifteen in the surgical group and seven of eighteen in the functional treatment group (risk difference: 32%; 95% confidence interval: 6% to 58%). The mean ankle score did not differ significantly between the groups (mean difference: 8.3 points; 95% confidence interval: —0.03 to 16.6 points). Stress radiographs revealed no difference between groups with regard to the mean anterior drawer (—1 mm in the surgical group and 0 mm in the functional treatment group; mean difference: 0.7 mm; 95% confidence interval: —1.4 to 2.7 mm) or mean tilt angle (0° in both groups; mean difference: 0.1°; 95% confidence interval: —3.2° to 3.5°). Grade-II osteoarthritis was observed on magnetic resonance images of four of the fifteen surgically treated patients and in none of the eighteen functionally treated patients (risk difference: 27%; 95% confidence interval: 4% to 49%).


These findings indicate that, in terms of recovery of the preinjury activity level, the long-term results of surgical treatment of acute lateral ligament rupture of the ankle correspond with those of functional treatment. Although surgery appeared to decrease the prevalence of reinjury of the lateral ligaments, there may be an increased risk for the subsequent development of osteoarthritis.

Level of Evidence: 

Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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