Exploring influences and risk of bias of studies on return to sport and work after lateral ankle sprain: A systematic review and meta-analysis

Table 1 Best evidence synthesis for qualitative outcome assessment

Level of evidence	Study design
Level 1	Systematic Review or multiple RCTs
Level 2	One RCT or multiple comparative studies
Level 3	One comparative study or non-comparative research
Level 4	Expert opinion

RCT: Randomized controlled clinical trials.

Table 2 Study characteristics and patient geographics

Ref.	Study design	RTS or RTW	Sample size, n	Sex, F:M	Age, yr (± SD)	Patient population	Follow-up, month (± SD)	Loss to follow-up
Avci et al[25], 1998	RCT	RTW	57 (64 enrolled)	20:37	Mean = 28.9 (NR)	General	1.5	7 (11)
Bouveau et al[32], 2022	RCS	RTS	40	17:23	Median = 32.9 (range: 15.6-59.9)	Active population	Median 28.8	NA
Cooke et al[13], 2009	RCT	RTW	584	247:337	Mean = 30 (± 10.8)	General	9	34 (6)
Eiff et al[35], 1994	RCT	RTW	82	NR	Range = 16-50 (mean/median: NR)	Military	12	6 (7)
Hong et al[40], 2022	PCS	RTS	147	16:131	Mean = 24.4 (± 4.9)	Athletes	24	0
Hou et al[30], 2022	RCT	RTS	70	36:34	Arthroscopic: Mean = 28.3 (± 5.4); open surgery mean = 28.6 (± 4.8)	Active population	24	10 (13)
Hupperets et al[27], 2009	RCT	RTS	552	248:274	Mean = 28 (± 11.7)	Athletes	12	14 (3)
Leanderson et al[38], 1995	RCT	RTW	73	25:48	Mean = 28 (NR)	General	2.5	NR
Lee et al[41], 2019	PCS	RTW	18	9:9	Mean = 19.3 (± 3.0)	Athletes	Mean = 28.8 (± 4.3)	0
Lee et al[42], 2020	RCS	RTW	125	35:90	Mean = 32 (± 7)	Military	Min 12, Mean 84 (NR)	NR
Liu et al[43], 2022	RCS	RTS	64	20:44	Mean one anchor = 30.5 (± 9.5); mean two anchor = 29.6 (± 8.0)	Active population	24	NR
May et al [42], 2022	RCS	RTS	59	21:20a	Mean returners = 27.2 (± 9.3); mean non-returners = 27.1 (± 7.7)	Active population	Min 24	18 (30)
Melton et al[33], 2018	RCS	RTW	127	10:117	Mean = 30.4 (± 6)	Military	1	0
O’Connor et al[26], 2020	RCT	RTW	60	20:40	Mean = 29.5 (NR)	General	1	10 (17%)
Punt et al[28], 2015	RCT	RTS	90	39:51	Wii Fit™ mean = 34.3 (± 10.7); physical therapy mean = 34.7 (± 11.3); no therapy mean = 33.5 (± 9.5)	General	1.5	2 (2%)
Razzano et al[29], 2019	RCT	RTS	61	28:33	Mean = 23 (NR)	Athletes	4	0
Rhon et al[36], 2021	RCS	RTS	6150	8818:15684b	Median = 31.75 (range: NR)b	Military	12	NA
Slatyer et al[24], 1997	RCT	RTW	364	54:310	Range = 18-35 (median: NR)	Military	6	0
Takao et al[31], 2020	PCS	RTS	93	65:28	Mean = 22.2 (± 12.5)	Athletes	12	NR
Wang et al[34], 2023	RCT	RTS and RTW	64	39:22	Open mean = 28.6 (± 8.1); arthroscopic mean = 27.1 (± 7.7)	Generalized joint laxity patients	24	3 (4.7)
White et al[23], 2016	PCS	RTS	42	5:37	Median = 22 (range: NR)	Elite athletes	Median = 44 (range: NR)	0

Data are n (%).

^aSex reported on 41 patients excluding the lost to follow (n = 18).

^bSex and mean age were only reported for the initially identified cohort (n = 24502) and not for the final included cohort (n = 6150).

F: Female; M: Male; Min: Minimum; NA: Not available; NR: Not reported; PCS: Prospective cohort study; RCS: Retrospective cohort study; RCT: Randomized controlled trial; RTS: Return to sport; RTW: Return to work; SD: Standard deviation.

Table 3 Risk of bias of included cohort studies and clinical trials according to the Risk of Bias in Non-randomized Studies-Interventions

Ref.	Confounding	Selection of participants	Classification of interventions	Deviation from intended interventions	Missing data	Measurements of outcomes	Selection of the reported results	Overall risk of bias
Bouveau et al[32], 2022	Low	Low	Low	Low	Moderate	Low	Low	Moderate
Hong et al[40], 2022	Low	Moderate	Low	Low	Low	Low	Low	Moderate
Lee et al[41], 2019	Low	Moderate	Low	Low	Low	Low	Low	Moderate
Lee et al[42], 2020	Moderate	Low	Low	Low	Moderate	Low	Low	Moderate
Liu et al[43], 2022	Moderate	Moderate	Low	Low	Low	Low	Low	Moderate
May et al[44], 2022	Moderate	Moderate	Moderate	Low	Low	Low	Low	Moderate
Melton et al[33], 2018	Moderate	Low	Low	Low	Moderate	low	low	Moderate
Rhon et al[36], 2021	Moderate	Moderate	Low	Low	Low	Low	Low	Moderate
Takao et al[31], 2020	Low	Moderate	Low	Low	Moderate	Moderate	Low	Moderate
White et al[23], 2016	Low	Moderate	Low	Low	Low	Low	Low	Moderate

Table 4 Quality and risk of bias of included randomized controlled clinical trial studies according to the Cochrane Risk of Bias tool

Ref.	Random sequence generation	Allocation concealment	Blinding of participants and personnel	Blinding of outcome assessment	Incomplete outcome data	Selective outcome reporting	Overall risk
Avci et al[25], 1998	Low	Low	High	High	Low	Low	High
Cooke et al[13], 2009	Low	Low	High	Unclear	Low	Low	High
Eiff et al[35], 1994	Low	Unclear	High	Unclear	Low	Low	High
Hou et al[30], 2022	Low	High	High	Unclear	Low	Low	High
Hupperts et al[27], 2009	Low	Low	High	Low	Low	Low	High
Leanderson et al[38], 1995	Low	Unclear	High	Unclear	Low	Low	High
O’Connor et al[26], 2010[26]	Low	Low	High	High	Low	Low	High
Punt et al[28], 2015	Low	Low	High	Low	Low	Low	High
Razzano et al[29], 2019	Low	Low	High	Low	Low	Low	High
Wang et al[34], 2023	High	High	High	Unclear	Low	Low	High
Slatyer et al[24], 1997	Low	Low	Low	Low	Low	Low	Low

Table 5 Outcomes of return to sport

Ref.	Intervention + patients (n)	Rate of RTS	Time to RTS, d (± SD)	P value
Bouveau et al[32], 2022	Arthroscopic repair (19)	16 (76.2)	NR	NS
	Arthroscopic reconstruction (21)	14 (67.7)	NR
Hong et al[40], 2022	Arthroscopic Broström with isolated injury (122)	122 (100)	Mean = 68.6 (range: 58-105)	P = 0.004
	Arthroscopic Broström with associated injury (125)	125 (100)	Mean = 82.8 (range: 65-132)
Hou et al[30], 2022	Arthroscopic Broström (36)	NR	Mean = 13.2 (± 2.4)	P = 0.023
	Open Bröstrom (34)	NR	Mean = 18.7 (± 3.1)
Lee et al[41], 2019	Open Broström early return (8)	8 (100)	Mean = 88.16 (± 9.12)	NR
	Open Broström late return (10)	10 (100)	Mean = 145.92 (± 39.52)
Liu et al[43], 2022	Arthroscopic one anchor suture (30)	23 (76.7)	NR	NS
	Arthroscopic two anchor suture (34)	26 (76.5)	NR
May et al[44], 2022	Modified Broström (41)	22 (53.6)	NR	NR
Punt et al[28], 2015	Wii Fit™ (30)	NR	Mean = 27.4 (± 20.3)	NS
	Physical Therapy 930)	NR	Mean = 39.7 (± 24.9)
	No treatment (30)	NR	Mean = 23.0 d (± 15.5)
Razzano et al[29], 2019	Electric Therapy (32)	2 month = 23 (71.9); 4 month = 27 (84.3)	NR	2 month, P = 0.029; 4 month, NS
	No treatment (29)	2 mo = 16 (55.2); 4 mo = 24 (82.7)	NR
Takao et al[31], 2020	A1: Unilateral arthroscopic repair (43)	NR	Mean = 41.6 d (± 18.2)	Group A vs group B, P < 0.001; group A1 vs group A2, NS; group B1 vs group B2, P = 0.001
	A2: Bilateral arthroscopic repair (16)	NR	Mean = 44.6 d (± 22.5)
	B1: Arthroscopic repair + ankle stabilization + postop nonweight bearing (22)	NR	Mean = 70.7 d (± 23.1)
	B2: Arthroscopic repair + ankle stabilization + postop weight bearing (12)	NR	Mean = 45.0 d (± 13.7)
Wang et al[34], 2023	Arthroscopic Broström (30)	21 (70.0)	Mean = 15.1 wk (± 7.8 wk)	NS
	Open Broström (31)	22 (71.0)	Mean = 17.2 wk (± 9.3 wk)
White et al[23], 2016	Modified Broström, isolated injury	NR	Median = 77 (range: 56-127)	P < 0.001
	Modified Broström, associated injuries	NR	Median = 105 (range: 82-178)

Data are n (%). NR: Not reported; NS: Not significant; RTS: Return to sport; SD: Standard deviation.

Table 6 Time of return to sport

Intervention type	Mean d to RTS (± SD)	Pooled mean d to RTS (± SD)
Arthroscopic surgery	13.2 (± 2.4)[30]; 105.7 (± 54.6)[34]	60 (± 46)
Open surgery	18.7 (± 3.1)[30]; 120.4 (± 65.1)[34]	70 (± 51)
All surgery	13.2 (± 2.4)[30]; 18.7 (± 3.1)[30]; 105.7 (± 54.6)[34]; 120.4 (± 65.1)[34]	65 (± 49)
Functional treatment	27.4 (± 20.3)[28]; 39.7 (± 24.9)[28]	34 (± 6.2)
No treatment	23 (± 15.5)[28]	23 (± 16)

RTS: Return to sport; SD: Standard deviation.

Table 7 Outcomes return to work

Ref.	Intervention + patients (n)	Rate of RTW, n (%)	Time to RTW in mean d (± SD)	P value
Avci et al[25], 1998	Soft cast tape (31)	NR	2.5 (NR)	P < 0.001
	Scotch plus tape (26)	NR	6.3 (NR)
Cooke et al[13], 2009	Below knee cast (142)	NR	7.7 (NR)	NR
	Aircast (149)	NR	9.6 (NR)
	Bledsoe brace (149)	NR	6.9 (NR)
	Tubular bandage (144)	NR	7.7 (NR)
Eiff et al[35], 1994	Early mobilization (40)	10 d = 22: (54); 3 wk = 30 (75); 6 wk = 36 (97); 3 month = 40 (100); 6 month = 40 (100)	4.3 (NR)	10 d, P < 0.001
	Immobilized (37)	10 d = 4 (13); 3 wk = 29 (79); 6 wk = 36 (96); 3 month = 37 (100); 6 month = 37 (100)	4.7 (NR)
Leanderson et al[38], 1995	Air-Stirrup ankle brace (39)	NR	5.3 (range: 0-26)	P < 0.05
	Compression bandage (34)	NR	9.1 (range: 0-21)
Lee et al[42], 2020	Isolated ankle stabilization with fibular periosteum augment (99)	88 (88.9)	NR	NS
	Isolated ankle stabilization without fibular periosteum augment (26)	18 (69.2)	NR
Melton et al[33], 2018	Modified Broström (127)	93 (73.2)	NR	NA
O’Connor et al[29], 2020	Tubigrip (18)	NR	5.2 (± 4.9)	NS
	Elastoplast (20)	NR	3.7 (± 3.5)
	No Support (16)	NR	5.8 (± 4.7)
Slatyer et al[24], 1997	Piroxicam (184)	173	2.74 (NR)	P < 0.001
	Placebo (180)	167	8.57 (NR)
Wang et al[34], 2023	Arthroscopic Broström (30)	NR	6.8 (± 2.1)	P = 0.006
	Open Broström (31)	NR	8.1 (± 2.4)

NA: Not available; NR: Not reported; NS: Not significant; RTW: Return to work; SD: Standard deviation.

Table 8 Time of return to work

Intervention type	Means d to RTW (± SD)	Pooled mean d to RTW (± SD)
Arthroscopic surgery	6.8 (± 2.1)[34]	6.8 (± 2.1)
Open surgery	8.1 (± 2.4)[34]	8.1 (± 2.4)
All surgery	6.8 (± 2.1)[34]; 8.1 (± 2.4)[34]	7.5 (± 0.7)
Functional treatment	6.3 (NR)[25]; 2.5 (NR)[253]; 7.7 (NR)[13]; 9.6 (NR)[13]; 6.9 (NR)[13]; 7.7 (NR)[13]; 4.3 (NR)[35]; 4.7 (NR)[35]; 9.1 (range 0-21)[38]; 5.3 (range: 0-26)[238]; 5.2 (± 4.9)[26]; 3.7 (± 3.5)[265]; 2.74 (NR)[249]	5.8 (± 2.2)
No treatment	5.8 (± 4.7)[265]; 8.57 (NR)[24]	7.2 (± 1.4)

NR: Not reported; RTW: Return to work; SD: Standard deviation.