Paper 60: Preliminary outcomes and gps device-measured load and performance following high ankle sprains and return-to-sport in division 1 football players: comparing semirigid fixation and non-surgical management

Objectives: Syndesmotic ligamentous injuries, or high ankle sprains, represent up to 25% of ankle injuries in contact sports, such as American football. However, guidelines on the management of high ankle sprains remain unclear, especially in high performance athletes. There is ongoing debate on both operative versus non-operative management, as well as, in those undergoing surgical fixation, i.e. the utilization of semirigid fixation (e.g., Arthrex Tightrope) versus rigid fixation (trans-syndesmosis screw). Additionally, little, if any, research has explored wearable, real-world data on performance and external load following return-to-sport for either operatively- or non-operatively-managed high ankle sprains. This pilot study had 2 primary objectives in a sample of Division 1 collegiate American football athletes following high ankle sprains: 1) we aimed to characterize post-treatment patient-reported outcomes and global positioning system (GPS) wearable device workload data from baseline through return-to-sport (RTS); and 2) we performed preliminary comparisons between athletes treated with either semirigid surgical fixation or non-surgical management.

Methods: We identified American football athletes at one Division 1, Power Four athletics program that had sustained high ankle sprains and underwent either non-operative management or semirigid surgical fixation (Arthrex Tightrope XP implant system) by a single foot and ankle specialist at our institution. Typical non-operative management included weightbearing as tolerated in a boot, anti-inflammatories, and a progressive rehabilitation, progressing as symptoms allowed. A standardized rehabilitation approach was followed for all surgical patients. As a part of routine workload monitoring by athletic training and strength and conditioning staff, football athletes wore a GPS-based workload monitor (Catapult Vector) during practices and competition; both pre-injury (baseline) and following RTS. Primary Catapult workload variables of interest included total distance covered, maximum speed, and total player load, averaged over a 10-day period prior to injury and following RTS. We contacted participants at follow-up (minimum of 2 years) via telephone to collect patient-reported outcome measures. These included the Foot and Ankle Ability Measure (FAAM) sport subscale, self-rating of current ankle function, as well as information regarding return to preinjury level of sport and relevant contextual factors, such as time from injury/surgery to 'go as can' (integration into sport) and 'full-go' (full sports participation). We compared continuous variables between groups using independent t-tests and categorical variables between groups using Chi-square tests.

Results: A total of 19 football athletes with high ankle sprains were included. Of these 19, 4 had bilateral high ankle sprains, resulting in a total of 23 treated ankle injuries. Of the 23 included high ankle sprains, 9 underwent semirigid surgical fixation and 14 underwent non-operative treatment. The average age at initial non-operative management or surgery for the entire cohort was 21.2 years. Demographic, sport, and treatment data are shown in Table 1. The majority of athletes in both the operative and non-operative groups eventually played at the professional level, and the majority of athletes in both groups were offensive linemen. All athletes planned to return to football, and all were able to return to their preinjury level (Table 2). Time between injury/surgery and 'go as can' as well as 'full-go' were shorter for the non-operative group compared to the operative group (Table 2). There were statistical trends toward shorter follow-up time and younger age at follow-up in the operative group, but these group differences did not reach statistical significance (Table 2). Additionally, at follow-up, the operative group reported higher FAAM sport scores, a higher proportion of self-reported normal ankle function, and a higher proportion that reported similar or better ankle performance compared to the non-operative group, but these group differences did not reach statistical significance (Table 2). Table 3 demonstrates GPS-based workload variables, both at baseline (prior to injury) and following RTS. These measures did not differ between groups, and values following RTS were similar to baseline.

Conclusions: To our knowledge, this is the first study to evaluate GPS wearable device workload data alongside patient-reported outcomes following semirigid surgical fixation or non-operative management for the treatment of syndesmotic ligamentous injuries (high ankle sprains). We found that all athletes that underwent either operative or non-operative treatment were able to return to preinjury sport, and resumed similar GPS device-measured workloads and performance as prior to injury. Whereas the operative group had longer times from treatment until returning to football activities, these differences were likely driven by higher injury severity in the operative group compared to the non-operative group. At mid-term follow-up, the operative group appeared to report higher levels of ankle-related function, however these differences were not statistically-significant. Further work will seek to add participants and available data to increase statistical power while also evaluating for severity of injury via radiographic injury assessment. Overall, our preliminary results suggest that semirigid surgical fixation of high ankle sprains allows for athletes to return to preinjury baseline while having equal (if not better) mid-term outcomes when compared to non-operative treatment.