Abstract
Background:
Fear of reinjury (FORI) can hinder recovery in several orthopaedic conditions, but its impact after augmented Broström repair is unknown. We sought to determine the prevalence of FORI and its association with functional outcomes in this setting. This study aims to determine whether patients experience FORI following augmented Broström repair and whether FORI impacts functional outcomes.
Methods:
80 patients who underwent Broström repair with InternalBrace augmentation were contacted to complete surveys containing questionnaires with Patient Reported Outcome Measurement Information System (PROMIS) measures of physical function (PF) and pain interference (PI), Cumberland Ankle Instability Tool (CAIT), and whether patients experienced current (at time of survey completion) activity limitations due to FORI.
Results:
64% (51/80) of patients reported postoperative FORI. Average follow-up was 3.9 years. Fear was associated with worse PF (49.9 ± 7.4 vs 54.9 ± 8.4, P = .01) and worse CAIT (19.1 ± 8.0 vs 23.2 ± 8.1, P = .04), and both differences exceeded the minimal clinically important difference (MCID). There was no significant difference in PI (49.8 ± 8.7 vs 46.5 ± 6.9, P = .06). There were no significant differences in the proportion of patients who reported FORI by age, sex, or BMI.
Conclusion:
FORI affected nearly two-thirds of patients and was linked to clinically meaningful functional deficits. Although PROMIS scores reached population means overall, addressing psychological barriers may further optimize outcomes after augmented Broström repair.
Level of Evidence:
Level IV, retrospective case series study.
Keywords: Broström, InternalBrace augmentation, fear of reinjury, PROMIS, Cumberland Ankle Instability Tool
Visual Abstract.
This is a visual representation of the abstract.
Introduction
Despite a scarcity of literature on fear of reinjury (FORI) in orthopaedic conditions, some studies indicate that FORI may serve as a barrier in recovery from various orthopaedic conditions, including ankle fractures, anterior cruciate ligament ruptures, Achilles ruptures, meniscus tears, and shoulder instability.2 -4,6,10,11,17 -20 No studies, to our knowledge, identify FORI as a specific problem in Broström repair for chronic lateral ankle instability (CLAI).
The Broström procedure is an anatomic reconstruction of the anterior talofibular (ATFL) and calcaneofibular (CFL) ligaments done for CLAI. Multiple modifications of this operation exist. For this study, “augmented” Broström refers to the addition of a suture tape–suture anchor construct using the InternalBrace system (Arthrex, Naples, FL) in addition to a standard Brostrom. 21 Patients who require a Broström have limited their activity and exhibit guarding behaviors in fear of further ankle sprains. Understanding the psychological impact of chronic instability may allow us to improve functional outcomes beyond mechanical stability.
May et al 22 suggested that fear might impact return to activity following Broström repair. However, this study did not examine the role of fear individually; rather it was included as one of many factors in a category of “non-ankle reasons” for why patients failed to return to activity. 22 It therefore remains unclear whether FORI, specifically, limits patients with CLAI who have undergone Broström repair. Patient Reported Outcomes Measurement Information System (PROMIS) measures of physical function (PF) and pain interference (PI) are validated metrics of patient function in foot and ankle. 13 PROMIS exhibits substantial generalizability and reliability, especially compared to several other commonly used legacy scales. 8 Cumberland Ankle Instability Tool (CAIT) is a validated metric of ankle stability. 12 A greater understanding of the role of FORI in patient recovery following Broström may enable physicians to improve patient functional outcomes following this procedure.
This study therefore aims to determine whether FORI limits patient functional outcomes following augmented Broström repair as measured by PROMIS and CAIT. We hypothesize that patients with FORI will have worse PROMIS and CAIT than those without FORI.
Methods
Population
This investigation was an institutional review board–approved retrospective study. All 574 patients who underwent lateral ankle ligament reconstruction at a single institution between 2013 and 2024 were reviewed independently by 2 investigators. All patients who underwent surgery failed nonoperative treatment including formal course of physical therapy and ankle bracing for minimum of 6 months. Revisions, concomitant Evans osteotomies, allografts, nonanatomic reconstructions, flexor digitorum longus transfers, progressive collapsing foot deformities, concomitant hindfoot arthrodesis, associated ankle arthroplasties, concomitant fractures, and nonaugmented Broström procedures were excluded. A total of 123 patients were eligible for the study and were contacted to complete surveys via REDCap containing PROMIS computerized adaptative tests (version 2.0), CAIT, as well as an additional question querying whether they experienced current (at time of survey completion) activity limitations due to FORI with a binary yes-no response option. Patients were contacted 5 times via both phone and email to obtain survey responses prior to ceasing contact. Eighty of 123 consented to participate and completed the survey. Patients were also classified based on CLAI etiology: isolated ligamentous instability (CLAI without anatomic deformity, n = 36), osteochondral defect (OCD, n = 15), or deformity (varus deformity, equinus contracture, n = 29). All surgeries were performed by foot and ankle fellowship-trained orthopaedic surgeons (n = 4). Augmentation was performed using the InternalBrace system (Arthrex, Naples, FL).
Outcomes
Primary outcome was whether FORI impacted PROMIS scores. Secondary outcome was the influence of FORI on postoperative CAIT.
PROMIS was developed for a US population and has a mean score of 50. 14 Higher PF indicates better physical function, whereas higher PI designates more pain interfering with activity. 14 PROMIS minimal clinically important difference (MCID) is a score of 3 to 30 reported in the literature. 14
Higher scores on CAIT indicate greater ankle stability with a maximum score of 30, whereas lower CAIT signifies less ankle stability. 12 The CAIT reported MCID in the literature is a change of 3 or greater. 24
Statistical Methods
We used 2-sample t tests to compare continuous variables and either Pearson χ2 or Fisher exact tests to compare categorical frequencies, as appropriate; all statistical tests were two-sided with a significance threshold of P <.05. Any patients with missing data were excluded as part of the initial exclusion criteria.
Results
Patient characteristics were similar between groups, including age, sex, BMI, and CLAI etiology (Table 1). Baseline characteristics were also similar between those who responded to the survey (responders) and those who did not respond to the survey (nonresponders) (Supplementary Table S1). Average follow-up in the full sample was 3.9 ± 1.3 years (range 1.0-11.0 years). There were no significant differences in length of follow-up by presence of FORI (3.6 ± 1.1 vs 4.2 ± 1.4, P = .53).
Table 1.
Patient Characteristics.
| No Fear of Reinjury, n (row %) (n = 29; 36%) |
Fear of Reinjury, n (row %) (n = 51; 64%) |
P Value | |
|---|---|---|---|
| Ankle instability etiology | .31 | ||
| Isolated ligamentous instability | 12 (33) | 24 (67) | |
| Deformity | 9 (31) | 20 (69) | |
| OCD | 8 (53) | 7 (47) | |
| Age, y, n (%) | .08 | ||
| 18-29 | 6 (45) | 8 (57) | |
| 30-40 | 6 (25) | 18 (75) | |
| 41-52 | 5 (25) | 15 (75) | |
| 53-64 | 10 (67) | 5 (33) | |
| 65+ | 2 (29) | 5 (71) | |
| Age, y, mean (SD) | 44.7 (15) | 42.1 (14) | .47 |
| Sex | .90 | ||
| Female | 17 (35) | 32 (65) | |
| Male | 12 (39) | 19 (61) | |
| BMI | .60 | ||
| 18.5-25 | 11 (41) | 16 (59) | |
| 25-30 | 11 (42) | 15 (58) | |
| 30-35 | 2 (20) | 8 (80) | |
| 35-55 | 5 (29) | 12 (71) | |
| Diabetes | .66 | ||
| No | 26 (35) | 48 (65) | |
| Yes | 3 (50) | 3 (50) | |
| Follow-up | .12 | ||
| 1 y | 0 (0) | 5 (100) | |
| >1-<3 y | 16 (44) | 20 (56) | |
| 3-<5 y | 6 (25) | 18 (75) | |
| 5-11 y | 7 (47) | 8 (53) | |
| Follow-up, y, mean (SD) | 3.6 (1.8) | 3.3 (1.8) | .53 |
| Smoking status | .57 | ||
| Current smoker | 0 (0) | 2 (100) | |
| Former/quit | 7 (32) | 15 (68) | |
| Nonsmoker | 22 (39) | 34 (61) | |
| Deltoid repair | .26 | ||
| No | 23 (41) | 33 (59) | |
| Yes | 6 (25) | 18 (75) |
Abbreviations: BMI, body mass index; OCD, osteochondral dissecans.
Sixty-four percent (51/80) of patients reported postoperative FORI (Table 1). Fear was significantly associated with worse PF (49.9 ± 7.4 vs 54.9 ± 8.4, P = .01; Table 2) and worse CAIT (19.1 ± 8.0 vs 23.2 ± 8.1, P = .04; Table 2). Although patients with FORI had worse PI, this value failed to reach statistical significance (49.8 ± 8.7 vs 46.5 ± 6.9, P = .06; Table 2). These values exceed the MCID for PF, PI, and CAIT.
Table 2.
Patient-Reported Outcomes by Fear of Reinjury.
| Fear of Reinjury | |||
|---|---|---|---|
| No, Mean (SD) (n = 29) |
Yes, Mean (SD) (n = 51) |
P Value | |
| PROMIS physical function | 54.9 (8.4) | 49.9 (7.4) | 0.01 |
| PROMIS pain interference | 46.5 (6.9) | 49.8 (8.7) | 0.06 |
| Postoperative CAIT | 23.2 (8.1) | 19.1 (8.0) | 0.04 |
Discussion
To our knowledge, no other study has described FORI as a specific limitation in patient recovery following a Broström-type lateral ankle ligament stabilizing procedure. Our cohort shows that FORI is common (64 %) and produces clinically meaningful deficits in both PROMIS-PF (≈ 5-point drop, above the MCID) and CAIT. Patients with FORI had PF 49.9 vs 54.9 without fear, and CAIT 19.1 vs 23.2, differences that exceed the published MCIDs.14,24
These findings suggest that FORI may serve as a critical barrier for patient function postoperatively and may result in patients perceiving less stability in their ankle. Therefore, FORI is an issue that physicians need to start addressing in order to improve outcomes following Broström, especially considering most patients who underwent Broström in this study reported FORI (64%). In addition to discussing range of motion and strength with all patients, surgeons should mention FORI, especially in patients who may not be progressing as well as imagined. Although this study did not evaluate strategies to mitigate FORI—as it was previously unknown that FORI was even an issue in Broström repair—future interventions could aim to screen patients for comorbid depression and anxiety, work closely with physical therapists to identify patients with FORI, and connect high-risk patients with sports psychologists. 1 FORI should be discussed with all patients, as we currently do not have a validated, reliable metric for predicting which patients are at high risk, as it was previously unknown that FORI proved such a substantial limitation in recovery from Broström. Future investigations need to evaluate these various strategies (screening patients for comorbid depression and anxiety, employing physical therapists and sports psychologists) for combatting FORI in these patients. Future investigations should also develop a validated metric to screen patients who may be at high risk for FORI following surgery. Our study team was not able to assess who may be at high risk preoperatively because we did not know that FORI was an issue, and we therefore could not screen for an issue that we did not know existed. Nevertheless, FORI is an unrecognized and untreated problem in Broström, and tackling FORI has the potential to improve our outcomes substantially if we do start addressing the psychological components of recovery beyond mechanical stability and strength.
Interestingly, there was no significant difference in PI between patients with and without FORI; however, patients with FORI had worse PI and this difference in PI scores reached the MCID reported for PROMIS, which may suggest that FORI impacts PI as well. 14 It is unclear whether this difference reaches statistical significance in a larger sample. However, the lack of statistical significance can also be explained by the role of FORI, which may impact function to a greater degree than pain. Therefore, functional limitations postoperatively may be driven by psychological rather than pain-related barriers.
Even with FORI, patients were able to achieve population mean functional outcomes as measured by PROMIS. Patients without FORI achieved PF and PI superior to the population mean with InternaBrace augmentation. These findings suggest that InternaBrace augmentation is a promising surgical management strategy for patients with CLAI that effectively stabilizes the ankle.5,7,9,16
This study has some limitations—notably the retrospective design. This study lacked preoperative outcome measures and patient expectations from surgery to compare patient baseline to postoperative scores. However, the focus of the study is to determine whether current function as measured by PROMIS is affected by FORI and therefore preoperative outcome measures are not required to come to this conclusion. Not everyone eligible to respond to the survey participated, which may introduce response bias. However, there were no significant differences between responders and nonresponders in terms of baseline characteristics, and our study had a 65% (80/123) response rate, which exceeds acceptable survey response rate values reported in the literature for PROMIS.15,23 This study also did not assess what factors (including CLAI etiology) may influence FORI, as it was impossible to screen for an issue (FORI) that we did not know existed. Clinical heterogeneity (eg, OCD lesions, varus deformity) may also confound the FORI-function relationship and was not analyzed separately. As with all patient-reported outcome studies, this investigation was subject to measurement bias—patients self-reported whether they experienced FORI, and patients may have interpreted survey questions differently, which may limit the accuracy of self-reported FORI. Future studies should develop a validated metric for assessing FORI and adopt a prospective study design that includes this validated metric for assessing FORI. Moreover, FORI may be more pronounced at different postoperative intervals. However, patients were asked whether they experienced FORI at the time of survey completion, and there were no significant differences in length of follow-up by FORI, which suggests that FORI may impact patients to a significant degree regardless of postoperative time interval. Lastly, as an observational study, causality cannot be established—poor function driving fear may be possible rather than fear driving poor function. Nevertheless, our study reveals a statistically and clinically significant association between FORI and worse outcomes.
Despite these limitations, this study importantly uncovers FORI as a barrier in Broström repair. Now that FORI is identified as an issue, we can develop solutions to address FORI to improve clinical outcomes in CLAI. Strategies to mitigate FORI in other orthopaedic conditions beyond augmented Broström should also be investigated.
Conclusions
Most patients (64%) experience FORI following augmented Broström procedure. FORI may limit patient function following repair, as PF of patients with fear was significantly lower than PF of patients without fear. Despite FORI, however, patients achieve population mean PROMIS scores with the augmented Broström procedure. Efforts should be directed toward addressing the psychological barriers that may impact recovery in patients with lateral ankle instability.
Supplemental Material
Supplemental material, sj-pdf-1-fao-10.1177_24730114251363915 for Fear of Reinjury Limits Patient Functional Outcomes as Measured by PROMIS Following Augmented Broström Procedure by Steven M. Hadley, Rachel Bergman, Sarah J. Westvold, Tanya Kukreja, Carolyn J. Hu, Ryan Filler, Muhammad Y. Mutawakkil, Milap Patel and Anish R. Kadakia in Foot & Ankle Orthopaedics
Supplementary Table S1.
Characteristics of Responders vs Non-Responders.
| Nonresponders, n (%) (n = 43; 35%) |
Responders, n (%) (n = 80; 65%) |
P Value | |
|---|---|---|---|
| Age | .88 | ||
| 18-29 y | 6 (14) | 14 (18) | |
| 30-40 y | 13 (30) | 24 (30) | |
| 41-52 y | 14 (33) | 20 (25) | |
| 53-64 y | 6 (14) | 15 (19) | |
| 65+ y | 4 (9) | 7 (9) | |
| Sex | >.99 | ||
| Female | 26 (60) | 49 (61) | |
| Male | 17 (40) | 31 (39) | |
| BMI | .16 | ||
| 18.5-25 | 8 (19) | 27 (34) | |
| 25-30 | 14 (33) | 26 (33) | |
| 30-35 | 11 (26) | 10 (13) | |
| 35-55 | 10 (23) | 17 (21) | |
| Smoking status | .74 | ||
| Current smoker | 2 (5) | 2 (2.5) | |
| Former/quit | 10 (23) | 22 (28) | |
| Nonsmoker | 31 (72) | 56 (70) | |
| Diabetes | .44 | ||
| No | 42 (97) | 74 (93) | |
| Yes | 1 (2) | 6 (8) | |
| Ankle instability etiology | .07 | ||
| Isolated ligamentous instability | 25 (58) | 36 (45) | |
| Deformity | 7 (16) | 29 (36) | |
| OCD | 11 (26) | 15 (19) | |
| Deltoid repair | .56 | ||
| No | 33 (77) | 56 (70) | |
| Yes | 10 (23) | 24 (30) |
Abbreviations: BMI, body mass index; OCD, osteochondral dissecans.
Footnotes
ORCID iDs: Steven M. Hadley, Jr, BA, 
https://orcid.org/0000-0003-2694-7334
Rachel Bergman, MD,
https://orcid.org/0000-0002-6702-8871
Sarah J. Westvold, MPH,
https://orcid.org/0009-0004-2060-2137
Tanya Kukreja, BA,
https://orcid.org/0009-0005-4674-3146
Carolyn J. Hu, BS,
https://orcid.org/0000-0001-6218-4034
Ryan Filler, MD,
https://orcid.org/0009-0007-6111-8810
Muhammad Y. Mutawakkil, MD,
https://orcid.org/0000-0002-8622-6793
Anish R. Kadakia, MD,
https://orcid.org/0000-0003-1023-6407
Ethical Approval: This study received ethical approval from the Northwestern University IRB (STU00210935) on November 19, 2019.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Steven M. Hadley Jr, BA, reports disclosures related to manuscript from HydroCision, Inc: consultant. Anish R. Kadakia, MD, reports disclosures related to manuscript from Arthrex: consultant, royalties, speakers’ bureau; DePuy Synthes: royalties; Elsevier: royalties. Disclosure forms for all authors are available online.
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Associated Data
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Supplementary Materials
Supplemental material, sj-pdf-1-fao-10.1177_24730114251363915 for Fear of Reinjury Limits Patient Functional Outcomes as Measured by PROMIS Following Augmented Broström Procedure by Steven M. Hadley, Rachel Bergman, Sarah J. Westvold, Tanya Kukreja, Carolyn J. Hu, Ryan Filler, Muhammad Y. Mutawakkil, Milap Patel and Anish R. Kadakia in Foot & Ankle Orthopaedics