Perspectives on Ligament Augmentation Techniques: A Survey of the American Orthopaedic Foot & Ankle Society

Abstract

Category: Ankle; Midfoot/Forefoot Introduction/Purpose: Ligament augmentation techniques (LATs) are surgical procedures in which anatomical ligaments are repaired or reconstructed with utilization of a synthetic ligament which spans from bone to bone and is fixated intra- or trans-osseously. There is an extensive, and growing, body of literature reporting LAT use in the foot and ankle. The prevalence of LAT use in the clinical practice of foot and ankle surgery is not well reported. Furthermore, indications for LAT use, such as patient characteristics, are not clearly defined. Surgical decision-making regarding LAT use is not characterized, and the influence of surgeon characteristics on use of LATs has also not been studied. This survey of the AOFAS membership aimed to understand foot and ankle surgeon preferences and practices in utilizing LATs. Methods: Survey questions were generated by a committee of experienced researchers and foot and ankle surgeons. Survey invitations were sent to the membership of the AOFAS, and only attending-level physicians were polled. There were 55 possible questions, which were gated by branching logic pertinent to the respondent’s characteristics and practices. Results were analyzed with descriptive statistics. Analysis of significance between groups was generated using the chi-squared test. A p-value of < 0.05 was considered statistically significant. Results: In total, 204 of 205 surveys received were completed (99.5%). 78.4% of surgeons practice in North America, across a diverse geographic span. Most physician have a primarily foot and ankle practice (88.1%), and 92.1% treat college or professional level athletes. 88.1% of surgeons utilize LATs in the foot and ankle. The most common indication for LAT use reported was quicker return-to-play (67.1%). The patient characteristics most influential of LAT use were elite athlete (67.2%), obesity (47.4%), manual laborer (46.9%), and cavovarus alignment (46.3%) (Figure 1). Significant diversity exists in level of surgeon concern for LAT device costs (p < 0.01), as well as in setting in which surgeons learned their LAT skills (p < .01). 97.7% of respondents who use LATs augment the ATFL. Conclusion: LATs are widely used by the membership of the AOFAS. Surgeon characteristics have a large effect on their use of LATs, and rate of utilization. Many surgeons’ motivations for LAT use are centered around athletic participation, patient employment, and patient anatomy. Concern for safety and efficacy of LAT use is the primary detractor in the use of this technique. Vast diversity exists in the ligaments which are repaired with ligament augmentation. A multitude of novel constructs were self-reported, and techniques which are not reported in the literature were described. We can expect further progress in clinical use of LATs.