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Purpose The relationship between ligament remnant quality and postoperative outcomes after arthroscopic lateral ankle ligament repair for chronic lateral ankle instability is controversial. This study aimed to determine whether the signal intensity of the anterior talofibular ligament on preoperative magnetic resonance imaging and ligament remnant quality identified on arthroscopy are associated with recurrent ankle instability after arthroscopic lateral ankle ligament repair. Methods A total of 68 ankles from 67 patients with chronic lateral ankle instability who underwent arthroscopic lateral ankle ligament repair were retrospectively studied. The signal intensity of the anterior talofibular ligament was evaluated using T2-weighted magnetic resonance imaging. Arthroscopy was used to evaluate the thickness and mechanical resistance of the anterior talofibular ligament by hook palpation and to classify ankles into two groups: the present anterior talofibular ligament group with adequate mechanical resistance and the absent anterior talofibular ligament group with no mechanical resistance. The outcomes included recurrent ankle instability (respraining of the operated ankle after surgery) and Self-Administered Foot Evaluation Questionnaire scores. Results Thirteen ankles were diagnosed with recurrent ankle instability. Patients with a high anterior talofibular ligament T2 signal intensity experienced more recurrent ankle instability than those with a low intensity. As determined via arthroscopy, the absent anterior talofibular ligament group had a higher rate of recurrent ankle instability than the present anterior talofibular ligament group. There were no significant differences in Self-Administered Foot Evaluation Questionnaire scores between patients with high and low anterior talofibular ligament T2 signal intensity, as well as between absent and present anterior talofibular ligament groups based on arthroscopy. Conclusion Poor quality of the anterior talofibular ligament remnant could result in recurrent ankle instability after arthroscopic lateral ankle ligament repair. Therefore, when treating chronic lateral ankle instability, surgeons should consider ligament quality. Level of Evidence IV.

Purpose To compare the surgical outcomes of the two different ankle stabilization techniques. Methods This randomized controlled trial aimed to compare the outcomes of the modified Broström procedure with [calcaneofibular ligament (CFL) group] or without CFL repair [anterior talofibular ligament (ATFL) only group]. Of the 50 patients randomly assigned to two groups, 43 were followed up prospectively for ≥ 2 years (CFL group: 22 patients, 36.6 ± 13.1 months; ATFL Only group: 21 patients, 35.3 ± 11.9 months). Functional outcomes were assessed using the Karlsson–Peterson and Tegner activity level scoring systems. Anterior talar translation (ATT), talar tilt angle (TTA), and degrees of displacement of the calcaneus against the talus on stress radiographs were measured. All parameters were compared between the two groups. Multiple regression analysis setting the postoperative Karlsson–Peterson score as the dependent variable was performed to determine the significant variable. Results There were no significant differences between the two groups in functional (Karlsson–Peterson and Tegner activity level) scores at the last follow-up and their changes. There were no significant differences between the two groups in the ATT, TTA, their differences compared with the contralateral ankles, and degrees of displacement of the calcaneus against the talus at the last follow-up. Osteochondral lesion of the talus rather than CFL repair was the significant variable related to functional outcome. Conclusion The modified Broström procedure with additional CFL repair did not result in a significant advantage in any measured outcome at 3 years. Level of evidence Randomized controlled trial, Level I.

Purpose The Broström-Gould procedure, with the repair of the anterior talofibular ligament (ATFL) combined with the transfer of the extensor retinaculum, is considered the gold standard procedure for the management of chronic lateral ankle instability (CLAI). Lateral ligament reconstruction is considered if the ATFL remnant quality is poor or the ATFL has been damaged beyond the ability to suture it. It remains unclear whether not repairing the ATFL remnant produces comparable functional outcomes to the classical Broström-Gould procedure. Methods This retrospective cohort study included 84 patients with CLAI undergoing either repair or non-repair of the ATFL remnant using an all-inside arthroscopic Broström-Gould procedure from 2015 to 2018. The Visual Analogue Scale (VAS) scores, American Orthopedic Foot and Ankle Society (AOFAS) scores, Karlsson Ankle Functional Score (KAFS), Anterior Talar Translation (ATT), Active Joint Position Sense (AJPS), and the rate of return to sports were compared in both groups. Results All the functional scores (VAS, AOFAS, KAFS, ATT, AJPS) significantly improved in both groups at 1 and 2 years after surgery. At all the follow-up time points, the VAS, AOFAS, KAFS, ATT, AJPS, and the rate of return to sport scores were comparable between the repair and non-repair group. Conclusion There are no statistically significant differences in postoperative outcomes between ATFL remnant repair and non-repair for the management of CLAI using the all-inside arthroscopic Broström-Gould procedure. From the clinical viewpoint, the present study shows that the potential differences in clinical outcomes between ATFL remnant repair and non-repair are likely not relevant when performing an all-inside arthroscopic Broström-Gould procedure for CLAI. Level of evidence III.

Purpose Although arthroscopic repair of the anterior talofibular ligament (ATFL) is widely performed, the effect of posterior talofibular ligament (PTFL) injury on clinical outcomes remains unclear. This study aimed to evaluate the magnetic resonance imaging (MRI) findings of the PTFL in chronic lateral ankle instability (CLAI) and determine whether the presence or absence of PTFL injury affected the postoperative outcomes of arthroscopic ATFL repair. Materials and methods Forty ankles of 35 patients who underwent arthroscopic repair for CLAI were included in this study as the experimental group, together with 25 ankles of 24 patients without CLAI as the control group. The PTFL thickness (PTFLT) and PTFL cross-sectional area (PTFLCSA) were measured using MRI and compared between the control and CLAI groups. The clinical outcomes of arthroscopic repair were compared between ankles with and without PTFL injuries. Results The mean PTFLT and PTFLCSA values were significantly higher in the CLAI group than in the control group. The PTFLT and PTFLCSA in the PTFL injury group were significantly larger than those in the non-injury group in the CLAI group. Postoperatively, there were no significant differences in clinical scores and talar tilt angles on stress radiographs between ankles with and without PTFL injury; however, instability recurrence was frequently observed in ankles with PTFL injury (32.1%) compared to the ankles without PTFL injury (16.7%). Poor-quality ATFL remnant, ATFL inferior fascicle, and calcaneofibular ligament injuries were frequently observed in ankles with PTFL injuries. Conclusions Our findings indicate that PTFL injury is highly associated with CLAI but it does not affect postoperative clinical scores. However, postoperative instability recurrence was more often observed in ankles with PTFL injuries, given that they frequently have poor-quality ATFL remnants and CFL injuries. Evidence level Level III

Purpose To compare the clinical outcomes, rate of return to sports, postural control, and muscle strength between the arthroscopic and open modified Broström procedure for chronic lateral ankle instability (CLAI) patients. Methods From September 2018 to April 2019, 70 patients diagnosed with CLAI were prospectively included with arthroscopic modified Broström procedure ( n  = 36) and open modified Broström procedure ( n  = 34). They were evaluated at five time points (preoperation and 3 months, 6 months, 1 year and 2 years postoperatively). The main results examined the rate of return to sports, American Orthopaedic Foot and Ankle Society Score (AOFAS), Foot and Ankle Ability Measure (FAAM), visual analogue scale (VAS), centre of pressure (COP) excursion velocity, time to boundary (TTB), plantar pressure, isokinetic muscle strength and complications. Results Compared with the open group, the arthroscopic group demonstrated a significantly shorter period of return to the preinjury sport (13.2 ± 2.4 weeks vs. 18.7 ± 3.1 weeks, P  = 0.023) and a higher early sport ratio (80.6 vs. 61.8%, P  = 0.011) combined with better FAAM sports and AOFAS at 3 months and 6 months postoperatively and VAS at 3 months postoperatively. In addition, better anterior–posterior postural control stability, less time to peak force under lateral hindfoot and better dorsiflexion strength were shown in the arthroscopic group at 6 months postoperatively. No significant difference was found in clinical scores, posture control or muscle strength at the 1- or 2-year follow-up between the two groups. Conclusions Shorter period and higher rates of return to sport activities and better clinical scores, posture control and muscle strength were achieved in the arthroscopic group at 6 months postoperatively, and no clinical differences were found between arthroscopic and open modified Broström procedure 1 year or 2 years postoperatively. Arthroscopic modified Broström procedure is a reliable procedure for CLAI injuries with the demand for fast exercise recovery. Clinical registration ChiCTR1900023999. Level of evidence II.

Background Chronic lateral ankle instability (CLAI) often arises from inadequately managed injuries to the lateral collateral ligaments, potentially leading to osteochondral lesions of the talus (OLT) and subsequent osteoarthritis. Hepple Stage V OLT, characterized by subchondral cysts, presents a significant therapeutic challenge. This study aimed to evaluate the efficacy of arthroscopic anterior talofibular ligament (ATFL) repair combined with retrograde drilling and allograft bone grafting in patients with CLAI and Hepple Stage V OLT with an intact talar articular surface. Methods This retrospective, small-sample exploratory study included 12 patients (ten men; median age: 35 years) who underwent arthroscopic treatment (between January 2020 and December 2022) for chronic lateral ankle instability with subchondral cysts, specifically Hepple Stage V OLT cases with an intact talar articular surface, after failing non-surgical interventions. The ATFL was repaired using the all-inside Internal Brace (IB) augmentation with the arthroscopic modified Broström operation. Treatment for OLT involved simultaneous retrograde drilling and allograft bone grafting. The median follow-up duration was 24 months (range: 20–35 months). The improvement of postoperative ankle pain was assessed using the Visual Analogue Scale (VAS), and the improvement of ankle function was evaluated using the American Orthopedic Foot ༆ Ankle Society (AOFAS) score and Foot༆Ankle Outcome Score (FAOS). Radiographic assessments were conducted at a minimum of 12 months postoperatively. Results All 12 patients (12 ankles; 100%) returned for clinical and radiological follow-up at an average of 24 months (20–35 months) postoperatively. Subjective improvement was reported after arthroscopic surgery. The median AOFAS score demonstrated a substantial improvement from 67 preoperatively (range: 58–70) to 94 at the final follow-up (range: 90–98), with P  < 0.05. Similarly, The FAOS score improved from 65 preoperatively (range: 58–75) to 91 at the final follow-up (range: 89–97), with P  < 0.05. Radiographic follow-up results indicated satisfactory healing of the ATFL and favorable bone ingrowth post-subchondral cyst bone grafting. Conclusion Arthroscopic ATFL repair combined with retrograde drilling and allograft bone grafting yields favorable clinical and radiographic outcomes in patients with CLAI and Hepple Stage V OLT. This integrated approach addresses both ligament instability and subchondral cyst pathology, potentially delaying the progression of osteoarthritis.

Background Chronic lateral ankle instability (CLAI) is a common condition often associated with damage to the anterior talofibular ligament (ATFL). In cases where CLAI is accompanied by subtalar instability (STI) due to calcaneofibular ligament (CFL) injury, the optimal surgical approach remains controversial. While isolated ATFL repair has been shown to effectively restore ankle joint stability, it may be insufficient to address the subtalar joint instability caused by CFL damage. This study aimed to evaluate the clinical importance of CFL repair by comparing the outcomes of isolated ATFL repair versus combined ATFL and CFL repair. Methods A retrospective cohort study was conducted involving patients diagnosed with CLAI in conjunction with STI from January 2018 to January 2022. Participants were divided into two groups: one underwent isolated ATFL repair (ATFL group), and the other underwent combined ATFL and CFL repair (ATFL + CFL group). Clinical outcomes were assessed using the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS-AH), Karlsson Ankle Functional Score (KAFS) and Visual Analog Scale (VAS) scores, while radiological outcomes were evaluated by MRI and stress radiographs. Results All the functional scores significantly improved in both groups post-surgery. However, the ATFL + CFL group demonstrated superior functional recovery, with higher AOFAS scores and greater reductions in VAS pain scores compared to the ATFL group. Radiological evaluation indicated better restoration of subtalar joint stability in the ATFL + CFL group. At the final follow-up, 3 cases of recurrent instability were observed in the isolated ATFL repair group. No significant difference in other complication rates was observed between the two groups. Conclusion The study demonstrated the importance of CFL repair in patients with CLAI in conjunction with STI. While isolated ATFL repair is effective for ankle joint stability, combined ATFL and CFL repair offers superior outcomes by addressing both ankle and subtalar joint instability. These findings suggest that CFL repair should be considered in surgical planning for patients with STI to optimize functional recovery and long-term stability. Level of evidence Level III.

Purpose Compared with open surgery, arthroscopic anterior talofibular ligament (ATFL) repair has many advantages and good clinical outcome. Inferior extensor retinaculum (IER) reinforcement is a supplement procedure that increase the strength of the ATFL. There is still no gold standard for arthroscopic ATFL repair. The purposes of this study were to describe a simplified technique for arthroscopic ATFL repair with IER reinforcement and to analyze its preliminary clinical results. Methods Twenty-seven patients with chronic lateral ankle instability (CLAI) who underwent this simplified surgery were analyzed in this retrospective study. The patients’ characteristics and operative times were evaluated. Intraoperative photos, radiographs from the anterior drawer test and talar tilt test and postoperative MR images were recorded. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and visual analog scale (VAS) score were also recorded. With the assistance of a needle, we performed ATFL repair and IER reinforcement with one Pushlock anchor and nonabsorbable sutures. Results No complications namely skin necrosis, superficial fibular nerve injury or wound infection, were reported. The AOFAS score and VAS score improved from 64.74 ± 9.47 and 6.00 ± 1.56 to 90.74 ± 6.46 and 1.07 ± 1.09, respectively. The talar advancement and talar tilt angle were improved after surgery. One year after the operation, the ATFL appeared to be continuous on MR images. Conclusion In this study, we proposed a simple and effective arthroscopic ATFL repair with IER reinforcement technique. The short-term follow-up examination revealed satisfactory clinical outcomes. Our technique might be a new surgical option for the treatment of CLAI.

Background Chronic Lateral Ankle Instability (CLAI) is a common condition treated using either Anterior Talofibular and Calcaneofibular Ligament (ATFL and CFL) reconstruction or Modified Brostrom Procedure (MBP). However, the comparative efficacy of these approaches is not well-studied. Methods In this study, clinical data were retrospectively collected from 101 patients diagnosed with CLAI who underwent either ATFL and CFL reconstruction ( n  = 51) or the MBP ( n  = 50). Patients were comparable in terms of age, sex, Body Mass Index (BMI), post-injury duration, preoperative American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson score, Visual Analog Score (VAS), Anterior Talar Translation, and Talar Tilt Angle. Results The post-operative measures showed no significant differences in AOFAS Score, Karlsson Score, and VAS between both treatment groups. However, patients who underwent ATFL and CFL reconstruction showed significantly lower follow-up Anterior Talar Translation (mean = 4.1667 ± 1.3991 mm) and Talar Tilt Angle (mean = 5.0549 ± 1.6173°) compared to those who underwent MBP. Further, patients treated with ATFL and CFL reconstruction experienced a significantly longer postoperative recovery time (median = 6 weeks) compared to MBP (median = 3 weeks). Conclusions Although both therapeutic techniques were generally effective in treating CLAI, the ATFL and CFL reconstruction approach delivered superior control of Anterior Talar Translation and Talar Tilt Angle. However, its longer recovery time merits further study to optimize the balance between therapeutic efficacy and recovery speed.

Background The aim of this study is to report our institution’s experience regarding the application of allogeneic tendons for the reconstruction of malunited lateral malleolar avulsion fractures with chronic lateral ankle instability. Methods This retrospective study included 34 (34 ankles) patients surgically treated for malunited lateral malleolar avulsion fractures with chronic lateral ankle instability from January 2016 to December 2019. All patients underwent allogeneic tendon reconstruction. The pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores、Karlsson Ankle Functional Scores (KAFS) and visual analogue scale (VAS) scores were used to evaluate the functional recovery of the ankle joint. The final follow-up, based on radiographic assessment, including talar tilt and anterior talar translation, was performed to evaluate the stability of the postoperative ankle joints. Results Thirty-two patients (32 ankles) returned for final clinical and radiologic follow-up at an average of 29 (range 24–35) months and 2 patients (2 ankles) were lost to follow-up. The preoperative talus inclination angle (13.6 ± 1.9°) and anterior displacement (9.6 ± 2.8 mm) were re-examined under X-ray and found to be reduced to 3.4 ± 1.2° and 3.8 ± 1.1 mm, respectively (p＜0.01). The AOFAS scores increased from 58.5 ± 4.0 to 90.9 ± 3.8 and the Karlsson scores improved from 52.2 ± 3.6 to 89.8 ± 4.5, which was obviously better and the difference was statistically significant (P < 0.01). The VAS scores were significantly reduced from a preoperative mean of 6.8 ± 1.0 to 2.8 ± 0.9 postoperatively (p＜0.01). Conclusion In this population and with this follow-up, the application of allogeneic tendons to treat malunited lateral malleolar avulsion fractures combined with chronic lateral ankle instability appeared safe and effective.