Kerkhoffs et al. hebben binnen de Cochrane Collaboration systematische reviews bij acuut enkelletsel uitgevoerd naar (a) het effect van operatieve behandeling versus conservatieve behandeling, (b) het effect van immobilisatie versus functionele behandeling en (c) de effecten van verschillende vormen van functionele behandeling.^123-125

Operatieve behandeling versus conservatieve behandeling

De review van Kerkhoffs et al. beschrijft zeventien studies waarin het effect van operatief ingrijpen bij acuut enkelletsel is onderzocht in vergelijking met conservatieve behandeling.¹²³ De operatieve behandeling kon bestaan uit hechting of reconstructie van het ligamentum talofibulare anterius. De conservatieve behandeling bestond uit immobilisatie (bijvoorbeeld gips) of functionele behandeling (bijvoorbeeld een brace). De auteurs beschrijven een verschil in het voordeel van operatieve behandeling op het niveau van sportuitoefening, pijn en functionele instabiliteit. Op basis van een sensitiviteitsanalyse bleken de resultaten echter niet robuust, en bij toepassing van een ‘random effects model’ verviel, als gevolg van de heterogeniteit van de studies, het statistisch significante verschil. De auteurs concluderen dat er onvoldoende bewijs is voor het aantonen van een verschil tussen operatieve of conservatieve behandeling.

In Nederland, maar ook internationaal, bestaat consensus over de voorkeur voor conservatieve behandeling na acuut enkelletsel.¹ Operatief ingrijpen heeft langer arbeidsverzuim en hogere kosten tot gevolg.

Ook bij chronische (recidiverende) klachten geniet conservatieve behandeling in eerste instantie de voorkeur boven operatieve behandeling.^{35,53,126-128}

De behandeling van alle recidiverende enkelletsels zou moeten beginnen met een conservatieve behandeling gedurende 8 tot 12 weken. Bij aanhoudende klachten kan dan alsnog een operatie worden overwogen.

Immobilisatie versus functionele behandeling

Twintig studies zijn door Kerkhoffs et al. gebruikt om het verschil in effect tussen immobilisatie en functionele behandeling bij acuut enkelletsel te onderzoeken.¹²⁵ Immobilisatie bestond uit gips of spalk terwijl de functionele behandeling uit bandage, tape of brace kon bestaan. Functionele behandeling scoorde beter op maar liefst zeven uitkomstmaten: terugkeer naar sport, tijd tot terugkeer naar sport, terugkeer naar werk, tijd tot terugkeer naar werk, zwelling, instabiliteit, patiënttevredenheid.

Verschillende vormen van functionele behandeling

Voor het onderzoeken van de verschillen tussen de vormen van functionele behandeling na acuut enkelletsel includeerde Kerkhoffs et al. tape, elastische bandage, veterbrace (lace-up brace), en semirigide brace in hun review.¹²⁴ De conclusie van de reviewers is dat elastische bandage minder complicaties tot gevolg heeft dan tape, maar vaker geassocieerd wordt met instabiliteit dan een semirigide brace. Een veterbrace lijkt effectief te zijn voor de vermindering van zwelling in vergelijking met een semirigide brace, elastische bandage en tape. Gebruik van een semirigide brace resulteerde in een snellere terugkeer naar werk in vergelijking met een elastische bandage. De reviewers geven in de discussie aan dat de voorkeur uit lijkt te gaan naar het gebruik van semirigide brace boven elastische bandage, en elastische bandage boven tape.

Definitieve conclusies ontbreken vanwege de grote variatie aan behandelmethoden en inconsistentie van periode van follow-up.

Op basis van de literatuur is niet duidelijk welke strategie het beste is. Een elastische bandage is makkelijk aan te brengen en comfortabel, zeker in de acute fase, maar geeft minder steun dan tape of brace. Zowel tape als brace verminderen de beweeglijkheid van de enkel na het aanbrengen ervan, maar tape en nonrigide braces gaan losser zitten als gevolg van activiteiten. Alleen semirigide braces behouden hun stevigheid.¹²⁹ Tape wordt geassocieerd met complicaties, zoals huidirritatie, terwijl braces oncomfortabel kunnen zijn in combinatie met het dragen van schoenen. In de ISAKOS-consensus wordt de voorkeur uitgesproken voor het gebruik van een (veter- of semirigide) brace boven tape.³ 

De Stichting Consument en Veiligheid heeft een onderzoek gedaan naar de kosten en baten van het gebruik van enkelbraces ter preventie van recidiverende enkeldistorsies bij veldvoetballers.¹⁷ Uit het onderzoek blijkt dat het gebruik van een brace niet kosteneffectief is indien de directe medische en indirecte kosten (arbeidsverzuim) worden berekend. De Stichting concludeert echter dat er sprake kan zijn van een kosteneffectieve interventie indien overige gevolgen (kwaliteit van leven, sportverzuim, pijn) en de toegenomen effectiviteit van de huidige braces worden betrokken in de berekeningen.

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