Arthroscopic Anatomical Repair of Anterior Talofibular Ligament for Chronic Lateral Instability of the Ankle: Medium‐ and Long‐Term Functional Follow‐Up

Abstract

Objective:
To evaluate the functional outcomes of arthroscopic anatomical repair of anterior talofibular ligament (ATFL) in the treatment of chronic lateral ankle instability (CLAI) during medium- and long-term follow-up.

Methods:
From September 2014 to August 2017, the data of 37 patients (23 males, 14 females; 12 left ankles, 25 right ankles) aged between 21 and 56 years, with an average age of 32.17 ± 6.35 years, presenting with CLAI, was retrospectively analyzed. Among them, 32 injuries were caused by sprain and five injuries were caused by car accidents. The course of the disease lasted for 12 to 60 months, with an average of 26.07 ± 13.29 months. All patients had intact skin around the ankle and no skin lesions. All patients underwent arthroscopic anatomical repair of ATFL, with the fixation of one to two anchors. Pre- and post-operative visual analogue scales (VAS), the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS), and the Karlsson Ankle Functional Score (KAFS) were compared to evaluate the curative effect of the operation.

Results:
The operation was successful in all 37 cases. The operation time ranged from 40 to 75 min, with an average of 51.25 ± 11.49 min. After surgery, all incisions healed in stage I and there were no complications such as nerve, blood vessel and tendon injury, implant rejection, or suture rejection. Hospital stays of postoperative patients were 3 to 5 days, with an average of 3.77 ± 1.36 days. All patients were followed for 24 to 45 months, averaging 33.16 ± 10.58 months. For three patients with CLAI combined with mild limitation of subjective ankle movement, joint activity was normal after rehabilitation function exercise and proprioceptive function training for 2 months. At the final follow-up, ankle pain had disappeared completely. The ankle varus stress test and ankle anterior drawer test were both negative. Range of joint motion was good. There was no lateral instability of the ankle and all patients returned to normal gait. The mean VAS score decreased to 1.12 ± 0.13, the AOFAS score increased to 92.53 ± 4.87, and the KAFS score increased to 93.36 ± 6.15. All the follow-up indexes were significantly different from those before surgery.

Conclusion:
Arthroscopic anatomical repair of ATFL for CLAI is precise, with less surgical trauma and reliable medium- and long-term effect.

Full text

CLINICAL ARTICLE
Arthroscopic Anatomical Repair of Anterior
Talofibular Ligament for Chronic Lateral Instability
of the Ankle: Medium- and Long-Term Functional
Follow-Up
Shi-ming Feng, MD
1,2
, Qing-qing Sun, MD
1
, Ai-guo Wang, MD, PhD
1,2
, Bu-qing Chang, MD
1
, Jian Cheng, MD
1
1
Hand and Foot Microsurgery Department, Xuzhou Central Hospital, Xuzhou and
2
Xuzhou Clinical College of Xuzhou Medical University,
Xuzhou, China
Objective: To evaluate the functional outcomes of arthroscopic anatomical repair of anterior talofibular ligament
(ATFL) in the treatment of chronic lateral ankle instability (CLAI) during medium- and long-term follow-up.
Methods: From September 2014 to August 2017, the data of 37 patients (23 males, 14 females; 12 left ankles,
25 right ankles) aged between 21 and 56 years, with an average age of 32.17 6.35 years, presenting with CLAI,
was retrospectively analyzed. Among them, 32 injuries were caused by sprain and five injuries were caused by car
accidents. The course of the disease lasted for 12 to 60 months, with an average of 26.07 13.29 months. All
patients had intact skin around the ankle and no skin lesions. All patients underwent arthroscopic anatomical repair
of ATFL, with the fixation of one to two anchors. Pre- and post-operative visual analogue scales (VAS), the American
Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS), and the Karlsson Ankle Functional Score (KAFS)
were compared to evaluate the curative effect of the operation.
Results: The operation was successful in all 37 cases. The operation time ranged from 40 to 75 min, with an average
of 51.25 11.49 min. After surgery, all incisions healed in stage I and there were no complications such as nerve,
blood vessel and tendon injury, implant rejection, or suture rejection. Hospital stays of postoperative patients were 3 to
5 days, with an average of 3.77 1.36 days. All patients were followed for 24 to 45 months, averaging
33.16 10.58 months. For three patients with CLAI combined with mild limitation of subjective ankle movement, joint
activity was normal after rehabilitation function exercise and proprioceptive function training for 2 months. At the final
follow-up, ankle pain had disappeared completely. The ankle varus stress test and ankle anterior drawer test were both
negative. Range of joint motion was good. There was no lateral instability of the ankle and all patients returned to normal
gait. The mean VAS score decreased to 1.12 0.13, the AOFAS score increased to 92.53 4.87, and the KAFS score
increasedto93.366.15. All the follow-up indexes were significantly different from those before surgery.
Conclusion: Arthroscopic anatomical repair of ATFL for CLAI is precise, with less surgical trauma and reliable
medium- and long-term effect.
Key words: Anterior talofibular ligament; Anatomical repair; Chronic lateral ankle instability; Minimally invasive surgery
Introduction
The lateral ligament of the ankle is a key ligament struc-
ture to maintain stability of the ankle, and consists of
the anterior talofibular ligament (ATFL), calcaneofibular lig-
ament (CFL), and posterior talofibular ligament (PTFL). Due
to the anatomical and motor characteristics of the ankle,
Address for correspondence Shi-ming Feng, MD, Hand and Foot Microsurgery Department, Xuzhou Central Hospital, No. 199, the Jiefang South Road,
Xuzhou, Jiangsu, China 221009 Tel: +86-0516-83956629, +86-018112007527, Fax: +86-0516-83840486; Email: fengshiming_04@163.com
Grant Sources: This study was supported by grants from the Jiangsu Provincial Medical Youth Talent Program (QNRC2016393), Six Talent Peaks
Project in Jiangsu Province (2019-WSW-173), and Xuzhou Key Research and Development Projects (KC18180).
Disclosures: None of the authors has any commercial associations or financial disclosures that might pose or create a conflict of interest with
information presented in this article.
Received 27 October 2019; accepted 6 February 2020
505
© 2020 THE AUTHORS.ORTHOPAEDIC SURGERY PUBLISHED BY CHINESE ORTHOPAEDIC ASSOCIATION AND JOHN WILEY &SONS AUSTRALIA,LTD.
Orthopaedic Surgery 2020;12:505–514 •DOI: 10.1111/os.12651
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.

approximately 85% of the ankle sports injuries are varus
injuries, which is damage to the lateral ligament structure,
and of which 62% are combined with ATFL injury
1,2
. Most
of the patients with an ankle varus injury can obtain satisfac-
tory results from conservative treatment for 3 to 6 months
3,4
.
However, 10% to 12% of patients still report lateral ankle
pain, repeated ankle sprains, leg giving way when walking,
and fear of walking at night for more than 6 months follow-
ing injury, and this can develop into chronic lateral ankle
instability (CLAI)
5
. CLAI is divided into symptomatic lateral
ankle instability and mechanical lateral ankle instability,
based on to the integrity of the lateral ankle ligament. If the
structure of the symptomatic lateral ankle ligament is com-
plete, satisfactory therapeutic effect can be obtained by pro-
prioceptive exercise
6
. Mechanical lateral ankle instability is
the true instability of the ankle due to rupture of the lateral
ligament of the ankle, and the stability of the lateral ankle
should be restored by operation
7
.
The current surgical treatment of CLAI is mainly
divided into anatomical repair of the ligament and strength-
ening of the lateral ligament. In open surgery, the Broström
procedure with direct ATFL repair and Broström-Gould pro-
cedure combined with extensor retinaculum suture to
strengthen the lateral ligament of the ankle are considered
the gold standard procedures for the treatment of CLAI
8,9
.
The above surgical procedures are performed for treatment
of CLAI in traditional open surgery. The traditional open
surgery has been widely used for decades, for it has been
proved to be an effective strategy with good surgical out-
comes. However, the procedure requires a curved incision
starting approximately 5 cm on the lateral ankle, and
includes the drawbacks of a long surgical incision and large
surgical trauma. With heightened requirements for postoper-
ative aesthetic appearance and functional recovery, mini-
mally invasive treatment of ankle sports injury is
increasingly sought by both doctors and patients. With the
development of arthroscopic technology in recent years,
arthroscopic repair of the lateral ankle ligament has become
one of the hotspots in foot and ankle surgery and sports
medicine
10
. Through systematic analysis, Guelfiet al. com-
pared the results of open surgery and arthroscopic surgery
11
.
In the comparison of 505 cases involved in 13 open studies
and 216 cases involved in six arthroscopic studies, it is found
that both open surgery and arthroscopic surgery can obtain
excellent efficacy for the treatment of CLAI. Although the
incidence of postoperative complications after arthroscopic
surgery is higher, the postoperative satisfaction of patients is
significantly higher than that of traditional open surgery
11
.
By comparing the data of 37 patients undergoing open
Broström repair surgery and 23 patients undergoing arthro-
scopic Broström repair surgery, Li et al. found that there was
no significant statistical difference in AOFAS, KAFS, and
Tegner score between the two groups after a 2-year follow-
up
12
. It is believed that arthroscopic surgery can achieve the
same effect as open surgery. However, as a minimally inva-
sive technology, arthroscopic surgery has less trauma and
faster postoperative recovery. Batista et al. treated 22 patients
with CLAI through the “All inside”lateral ligament repair
procedure by anterior medial and anterolateral portals
13
.
After 17–31 months of follow-up, the AOFAS score
increased from 63 points to 90 points and no CLAI recur-
rence was found after surgery. Batista et al. believed that the
“All inside”lateral ligament repair procedure can obtain
lower complications and lower local morbidity than the tra-
ditional open surgery, and should be the first-stage proce-
dure for surgical treatment of CLAI
13
. Through the above
literature analysis, it can be seen that although there is no
consensus on whether arthroscopic surgery or open surgery
is more effective for CLAI, more and more scholars recom-
mend the use of arthroscopic anatomical repair for CLAI.
Under the condition that the same function and result can
be obtained with open surgery, arthroscopic surgery is less
invasive and more satisfying. However, the current literature
reports mainly focus on the short-term effect of objective
direct repair to ATFL for CLAI
14–16
. There are seldom litera-
ture reports on the long-term functional outcome.
The purpose of this present retrospective study was as
follows. First, we aimed to investigate the therapeutic effect
of arthroscopic anatomical repair of ATFL in the treatment
of CLAI. Second, we evaluated whether the arthroscopic ana-
tomical repair of ATFL for CLAI has a good medium- and
long-term surgical outcome through a follow-up for at least
2 years. Third, we analyzed the complications, such as infec-
tion, nerve and tendon injury, and rejection. And we used
the American Orthopaedic Foot and Ankle Society Ankle-
Hindfoot Score (AOFAS), the Karlsson Ankle Functional
Score (KAFS), and other scoring criteria in an effort to pro-
vide a reference basis for the clinical application of this type
of operation.
Materials and Methods
This study was approved by the Hospital Ethics Commit-
tee and all selected patients provided signed informed
consent.
Inclusion and Exclusion Criteria
Inclusion criteria: (i) patients with chronic lateral ankle
instability diagnosed by physical examination and imaging
from September 2014 to August 2017; (ii) patients with regu-
lar conservative treatment for at least 6 months with no relief
of ankle symptoms; (iii) patients who received arthroscopic
anatomical repair with suitable residual tension and length
for ATFL; and (iv) patients with avulsion injury of ATFL fib-
ula side confirmed under the arthroscopy.
Exclusion criteria: (i) patients with symptomatic lateral
instability of the ankle or instability of other joints (subtalar
joint); (ii) patients with complicated diseases such as foot
and ankle deformities, abnormal line of force, fracture,
joint stiffness, or other ligament injuries; (iii) patients with
complicated central and peripheral neuromuscular atrophy
or ligament relaxation; (iv) patients who underwent ATFL
reconstruction or had higher requirements for exercise
10
;
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(v) patients with abnormal bone structure around the
insertion of the distal fibular ATFL ligament that could not
be implanted with anchors; (vi) patients with osteoarthritis
of the ankle or osteochondral injury requiring osteochondral
transplantation; (vii) patients who had received follow-up
within less than 12 months or those with complicated, serious
underlying diseases and could not tolerate the operation;
(viii) patients who had complicated rupture of the
calcaneofibularligamentorposteriortalofibular ligament; and
(ix) patients who had an avulsion fracture of lateral malleolus
and a diameter of fracture block greater than 5 mm.
Participants
We retrospectively analyzed data from 37 patients with CLAI
(23 males, 14 females; 12 left ankles, 25 right ankles), aged
between 21 to 56 with an average age of 32.17 6.35 years.
The Body Mass Index (BMI) was 22.69 5.13 kg/m
2
(range,
18.61 to 27.35 kg/m
2
). Thirty-two of these injuries were cau-
sed by sprain and five injuries were caused by car accidents.
The course of the disease lasted for 12 to 60 months, with an
average of 26.07 13.29 months. All patients had intact skin
around the ankle and no skin lesions. The preoperative
visual analogue scale (VAS), the American Orthopaedic Foot
and Ankle Society (AOFAS) Ankle-Hindfoot Score
17
, and
Karlsson Ankle Functional Score (KAFS)
18
were 4.79 1.85,
73.16 11.23 and 75.02 9.37, respectively.
Surgical Technique
Anesthesia and Position
In this group, nerve blocks of the lower extremity were used
for operative anesthesia in 21 cases, intraspinal block anes-
thesia in 11 cases, and general intravenous anesthesia in five
cases. The patient was placed in a supine position. A 7 cm-
high cushion was used on the hip of the affected side so that
the affected foot was in the neutral position of the ankle
under general anesthesia. The affected foot was placed on
the distal edge of the operating table. An airbag tourniquet
was placed mid-thigh. After using tourniquet, the balloon
pressure was set to 60 kPa.
Approach, Exposure, and Arthroscopy Debridement
Twenty milliliters of saline was injected at the horizontal
level of the ankle and 0.5 cm medial to the anterior tibial
tendon to fill the articular cavity and dilate the articular cap-
sule. A no. 11 scalpel blade was used to establish a medial
approach of 0.5 cm anterior to the ankle at the same point.
A mosquito hemostat was used to bluntly separate the
entrance to the ankle cavity. The joint lens was inserted to
explore the structure of the ankle cavity and anterior and lat-
eral tissue of the ankle. Hyperplastic synovial tissue of the
ankle, injured articular cartilage, and relaxed ATFL after
avulsion was observed in most patients. A 0.5 cm incision
was made at the level of the third peroneal muscle and lat-
eral superficial peroneal nerve under the light source of the
arthroscopic lens to establish an anterolateral approach to
the ankle. A 4.5 or 3.5 mm shaver was inserted into the inci-
sion to clean the hyperplastic synovium, corpus liberum, and
cartilage fragments in the ankle cavity. The condition
of exfoliation and injury of talus cartilage was explored.
Grinding was carried out according to each situation, and
talus microfracture was performed. Should be thoroughly
removed if the patients were combined with anterior ankle
soft tissue impact and the condition was caused by the Bas-
sett’s ligament. Then, the arthroscope was introduced in to
the ankle through the anterolateral portal. The stress test and
the anterior drawer test of the ankle were performed under
arthroscopy to reconfirm the lateral instability of the ankle.
The anterolateral approach was made in parallell at 1 cm dis-
tal and 1 cm anterior to the tip of the lateral malleolus. A
shaver was inserted to clean up the synovial and inflamma-
tory tissue around the lateral malleolus. The condition of
ATFL was explored. ATFL in all patients were avulsed from
the peroneal side (Fig. 1A).
Flaccid and tension-free ATFL and partial retraction of
the fibula avulsion end were observed in the arthroscopic
exploration. Two cases of small fractures with avulsion of the
fibula were thoroughly cleared. During the operation, the
residual proximal ATFL was clamped with a suture clamp.
When it could be retracted to the footprint region of the dis-
tal fibula and the ligament was reliable and powerful, ATFL
could be anatomically repaired. Otherwise, the Broström-
Gould procedure or ligament reconstruction was performed
(not included in this study). The anterior fibula approach
could be established according to the need of the operation
for the safety of the anterolateral fibula.
Anchor Insertion
Under the arthroscopy, the bone of the fibula footprint was
freshened using a Pituitary Rongeur or 1.0 mm Kirschner
wire drill (Fig. 1B). A double-wire anchor with a diameter of
3.5 mm was inserted in the middle area of the fibula foot-
print (Fig. 1C). The direction of the anchor was at an angle
of 30–45to the y-axis of the fibula. After clamping the
proximal end of the ATFL, a certain tension of the ATFL
should be maintained to explore the midpoint of the proxi-
mal region with relatively good structural quality of the
ATFL as the needle insertion point.
Repair the Ligament
The suture hook that had been pierced with the PDS sutural
line was inserted. The PDS sutural line was led to the outside
of the skin. A strand of the anchor sutural wire was intro-
duced into the ligament and penetrated out of the skin
through the PDS sutural line. The suture hook, which had
been pierced with the PDS sutural line, was inserted at the
vertical point of this position, which led to the same strand
of anchor sutural line (Fig. 1D). The above suture method
could be repeated once to strengthen the suture fixation. The
threading of another suture wire on the anchor could be car-
ried out in the same way (Fig. 1E). Finally, after confirming
the strength of the suture under a microscope, the valgus
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ankle was in dorsiflexion. The knot pusher was used to
suture one of the sutural lines and confirm the suture
strength. The other sutural line was sutured (Fig. 1F). Under
the microscope, the integrity and tension of the AFTL were
again explored. The anterior drawer test and ankle varus
stress test were performed again. After confirming the liga-
ment suture effect, the arthroscopy was withdrawn and the
approach incision was closed (typical cases are shown in
Figs. 2–4).
Postoperative Management
The ankle was fixed with a short leg brace in the position of
slight dorsal extension and valgus. Antibiotics were routinely
used within 24 h after surgery. On the second day after sur-
gery, patients were advised to do early weight-free functional
and isometric exercises of their lower limb muscles. Removal
of stitches was performed 2 weeks after operation. For
patients with talus cartilage injury in microfracture, the brace
remained fixed for 6 weeks after surgery; all other patients
were fixed for 4 weeks. After 4 (or 6) weeks, ankle-walking
boots were used. Postoperative improvement in muscle
strength around the ankle was assisted by the Rehabilitation
Department. After 8 weeks, ankle range of motion, varus
activity, and metatarsal flexion activity had increased. Twelve
weeks after surgery, the patients were advised to gradually
resume physical activity.
Postoperative Follow-up and Observation Indexes
Wound healing, ankle stability, and ankle function were eval-
uated using VAS, AOFAS, and KAFS scores. The last follow-
up time was when the patient was satisfied or unwilling to
continue in the follow-up.
Outcome Evaluation
In order to better record the ankle function of patients,
before scoring, all patients received the guidance of a
A B C
D E F
Fig. 1 Surgical diagrams of arthroscopic anatomical repair of anterior talofibular ligament (ATFL). (A) The intact ATFL was avulsed from the fibula.
(B) The bone of the fibula footprint was freshened using a Pituitary Rongeur or 1.0 mm Kirschner wire drill. (C) A double wire anchor with a diameter
of 3.5 mm was inserted in the middle area of the fibula footprint. (D) The suture method of the first anchor sutural wire. (E) The suture method of the
second anchor sutural wire. (F) The ATFL was sutured.
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professional physician so that they could better use the rat-
ing scale to reflect their real ankle function.
Visual Analogue Scale (VAS)
VAS scoring system is one of the most widely used rating
scales to evaluate pain in clinic. The scores range from 0 to
10 points, with 0 points indicating no pain and 10 points
indicating the most pain. The score results can be divided
into the following three degrees: 0–3 points is considered
mild pain that does not affect sleep; 4–6 points is considered
moderate pain that affects sleep, but still allows sleep; 7–10
points is considered intense pain where the person is unable
to sleep.
American Orthopaedic Foot & Ankle Society Scale
(AOFAS)
AOFAS is the most commonly used scoring system for ankle
function. The total score of the scoring system is 100 points,
including three parts: pain (40 points), function (50 points),
force line (10 points). Among them, the functional score
includes the following seven parts: limited mobility, maxi-
mum walking distance, whether the road surface affects
walking, gait, sagittal mobility, hind-foot mobility, ankle and
A
E
H I J K
F G
B C D
Fig. 2 A 32-year-old male with recurrent sprain of the left ankle with unstable walking for 18 months. The symptoms were not relieved after
12 months of regular conservative treatment. Arthroscopic anatomical repair of ATFL was performed. (A) Preoperative MRI plain scan of the left ankle
suggested that continuity of ATFL was interrupted. (B) Arthroscopic exploration showed horizontal avulsion of ATFL from the fibular stop point and
relaxation of ATFL without tension. (C) The footprint region of the fibula was observed under arthroscopy. After freshening, a double wire anchor with
a diameter of 3.5 mm was inserted. (D) The ATFL was sutured with a suture hook under arthroscopy. (E) Under arthroscopy, the anchor sutural line
was guided through the ATFL after the PDS sutural line was used to pass through the suture hook. (F) Fibular side of the ATFL was sutured with a
knot pusher. (G) The ATFL returned to normal tension and strength after suture under arthroscopy. (H) During the operation, the PDS sutural line was
used to guide the anchor wire through the external phase. (I) The surgical approach after suture. (J, K) Anterior–posterior and lateral X-ray films of the
ankle after surgery.
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hind-foot stability. The higher the score, the better the ankle
function.
Karlsson Ankle Function Score (KAFS)
Karlsson ankle function scoring system is mainly used to eval-
uate the functional recovery after ankle surgery, which consists
of eight parts: pain, swelling, subjective instability, rigidity,
climbing the stairs, running, work and life, and the use of
external aids. The total score of the scoring system is
100 points. The higher the score, the better the ankle function.
Complications
All complications were recorded, including infection, nerve
injury, blood vessel injury, tendon injury, implant rejection
or future rejection, ankle pain, ankle mobility, lateral ankle
stability, and joint instability recurrence. The evaluation of
surgical complications is of great significance to the feasibil-
ity and safety of the operation. Three experienced foot and
ankle surgeons who are totally unaware of the operation and
procedures evaluate the complications of the operation. If
there are three different opinions, they must discuss them to
reach the final conclusion.
A
D
G H I
E F
B C
Fig. 3 A 28-year-old female. The symptoms of CLAI were still presented after 8 months of conservative treatment. (A) Preoperative coronal MRI scan
of the left ankle suggested the interruption of ATFL. (B) Flaccid and tension-free ATFL that avulsed from the fibula point was observed under the
arthroscopy. (C) A double wire anchor with a diameter of 3.5 mm was inserted into the fibular footprint region. (D) The ATFL was sutured with a suture
hook under arthroscopy. (E) The ATFL was sutured and it returned to normal tension under arthroscopy. (F) External image of the arthroscopic
procedure during the operation. (G) The portals of the surgery after the operation. (H) Lateral X-ray of the ankle after surgery. (I) Anterior–posterior
X-ray of the ankle after surgery.
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Statistical Analysis
SPSS (version 19.0, Chicago, IL, USA) statistical software
was used to analyze the data. The quantitative data were
expressed as mean standard deviation. Pre-operative and
postoperative group comparison of classified variables by t-
test or nonparametric test, and the correlation analysis of
continuous variables by univariate analysis. The Spearman
test was used to evaluate associations among functional out-
comes of age, BMI, and disease duration. The αvalue was
set as 0.05 due to the univariate comparisons before and
after surgery. A Pvalue < 0.05 was considered statistically
significant.
Results
Follow-up
All the patients were followed up in the attending physician’s
clinic department from the time they were discharged. Rou-
tine reexamination after surgery was performed in all
patients, and the general circumstances and functional scores
were recorded at the follow-up time. The follow-up time
point and the information were collected at 6 months,
12 months, 24 months, 36 months, and 48 months after sur-
gery. However, the final exact follow-up time of all patients
may not follow the above time, due to personal factors relat-
ing to patients. All patients were followed for 24 to
45 months, with an average of 33.16 10.58 months.
General Results
The operation was successful in all 37 cases. The operation
time ranged from 40 to 75 min, with an average of
51.25 11.49 min. All patients underwent ankle synovial tis-
sue cleaning. During the operation, 19 patients underwent
talus microfracture. Six patients had complicated Bassett’s
ligament anterior ankle impingement syndrome and the Bas-
sett’s ligament was removed. Resection of old small fractures
of distal fibula was performed in two patients. The average
postoperative hospital stay was 3.77 1.36 days (inter-
quartile range 3–5 days).
Clinical Improvement
For three patients with CLAI combined with mild limita-
tion of subjective ankle movement, joint activity was nor-
mal after rehabilitation function exercise and proprioceptive
function training for 2 months. Ankle pain had disappeared
completely. Ankle varus stress tests were negative. Ankle
anterior drawer tests were negative. The range of motion
of the patients was great, and all patients returned to a
normal gait.
Implant Evaluation
At the last follow-up, there was no implant rejection or
suture rejection. All anchors were fixed firmly without obvi-
ous signs of failure or evidence of detachment.
A B C D
E F G H
Fig. 4 A 42-year-old male with the CLAI for 24 months. (A) Intra-operative arthroscopic exploration showed the ATFL avulsion from the fibular. (B) The
footprint region of the fibula was refreshed by using a 1.0 mm Kirschner wire drill. (C) Suture the first anchor sutural wire by using the PDS as a
guider. (D) Suture of the second sutural wire guided by PDS. (E) The sutured ATFL under arthroscopy. (F) External image of the arthroscopic procedure
during the operation. (G) Anterior–posterior X-ray of the ankle after surgery. (H) Lateral X-ray of the ankle after surgery.
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Functional Evaluation
The VAS score was decreased to 1.12 0.13 (t= 12.037,
P= 0.00). The AOFAS score was increased to 92.53 4.87
(t= 9.626, P= 0.00). The KAFS score was increased to
93.36 6.15 (t= 9.953, P= 0.00). All the follow-up indexes
were significantly different from those before operation
(Table 1). Subgroup analysis of all patients with CLAI rev-
ealed that the male patients resulted in similar functional
outcomes to the female patients at the last follow-up (VAS:
1.11 0.17 vs 1.14 0.20, t= 0.468, P= 0.644; AOFAS:
92.72 5.01 vs 92.16 4.23, t=−0.364, P= 0.719; KAFS:
93.65 5.37 vs 93.08 5.90, t= 0.295, P= 0.771). For
patients with BMI lower 25.0 kg/m
2
(n= 25), AOFAS
(93.24 3.37 vs 91.02 2.74, t= 2.136, P= 0.042) and
KAFS (94.35 5.02 vs 91.11 4.14, t= 2.076, P= 0.048)
functional scores were better than that with BMI over
25.0 kg/m
2
(n= 12). A negative correlation (nonlinear rela-
tionship) was found between AOFAS and BMI (Spearman
correlation coefficient, −0.032; P= 0.546) and KAFS and
BMI (Spearman correlation coefficient, −0.020; P= 0.759).
Thus, a higher degree of AOFAS and KAFS will result if the
BMI is lower.
Complications
All incisions healed in stage I after surgery, and there were
no complications such as wound infection, nerve injury, vas-
cular injury, and tendon injury. At the final follow-up,
patients had no mechanical or symptomatic instability of the
ankle. Good clinical outcomes in all the patients were
observed without instance of ankle pain, joint stiffness, and
arthritis until final follow-up.
Discussion
Surgical Management of CLAI
Most cases of symptomatic lateral ankle instability can be
treated with conservative treatment and rehabilitation exer-
cise. However, surgical treatment is needed for mechanical
lateral ankle instability. Because the residual ATFL ligament
in CLAI is still of good quality, and the position of the liga-
ment is superficial, the Broström procedure and modified
Broström procedure for suturing extensor retinaculum have
become the standard procedures for treatment of CLAI since
Broström reported successful treatment of CLAI in 1996 by
the direct repair of ATFL
19,20
. Although the previous
reports
21,22
indicated that use of the Broström procedure of
direct repair of ATFL for CLAI has achieved satisfactory
clinical results, there was still a 6% to 25% complication rate
including ankle pain, ankle swelling, and recurrence of lateral
ankle instability
23
. With the development of orthopaedic
endoscopy, some clinicians adopted arthroscopy-assisted
ATFL repair, first using arthroscopy to deal with ankle and
surrounding lesions, and then performing open suture repair
for ATFL
24
. Liszka et al. found that most patient cases pre-
senting with CLAI were complicated with medial talus carti-
lage injury, thus the traditional Broström procedure could
not detect and deal with the above-mentioned lesions
25,26
.
Arthroscopic exploration and debridement should be carried
out before the incision of Broström procedure to repair
ATFL
25
. In the current study, synovial tissue hyperplasia was
found in all patients. Nineteen of 37 patients had talus carti-
lage injury and six patients had anterior soft tissue impinge-
ment syndrome of the ankle. Therefore, arthroscopy is
beneficial to the comprehensive evaluation and treatment of
ankle lesions. Song et al.
27
compared arthroscopic ATFL
repair with open repair of ATFL in 207 patients with CLAI
and obtained the same ligament fixation strength and clinical
effect. Arthroscopic repair of ATFL can comprehensively
evaluate the ligament condition of ATFL, deal with the com-
plicated lesions, and realize satisfactory anatomical repair
28
.
Based on the clinical evaluation of this group, all 37 patients
included in the study achieved satisfactory clinical results.
The mean VAS score decreased to 1.12, the AOFAS score
increased to 92.53, and the KAFS score increased to 93.36.
All patients returned to normal gait, without mechanical
instability or symptomatic instability of the ankle. There is
no need for revision surgery.
Surgical Skills and Directions
Arthroscopic anatomical repair of ATFL for CLAI is per-
formed to achieve the expected therapeutic effect. It is crucial
to note the following: (i) It is necessary to strictly grasp the
inclusion and exclusion criteria, especially for patients with
abnormal force line of the lower extremities. Simple repair of
ATFL cannot achieve satisfactory results, and the postopera-
tive recurrence rate is very high. (ii) The hyperplastic syn-
ovium tissue around the ankle and peroneal tip needs to be
cleaned to reduce tissue swelling and pain. Before exploring
TABLE 1 Functional evaluation (mean SD)
Evaluation Tools Pre-operation Post-operation tvalue Pvalue
VAS 4.79 1.85 1.12 0.13 12.037 0.00
AOFAS 73.16 11.23 92.53 4.87 9.626 0.00
KAFS 75.02 9.37 93.36 6.15 9.953 0.00
AOFAS, American orthopedic foot and ankle society; KAFS, Karlsson ankle functional score; VAS, visual analogue scale. A value P< 0.05 was set as statistically
significant.
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ATFL, it is required that surgeons explore and deal with
ankle lesions, especially a talus cartilage injury. (iii) The
establishment of the anterior channel of the lateral malleolus
under arthroscopy should be carried out in the safe area to
avoid injury to the superficial peroneal nerve and sural nerve.
(iv) The small bone mass of lateral malleolus avulsion can be
removed to prevent the formation of corpus liberum and
impact
29
. (v) During the operation, the position of the
anchor should be located at the middle point of the footprint
region of the distal fibula, and the bone freshening of the
footprint region should be carried out before inserting the
anchor to facilitate better healing of ATFL. The direction of
the anchor should be at an angle of 30–45with the y-axis
of the fibula on the sagittal plane to prevent the distal end of
the fibula from piercing and splitting
30
. In the horizontal
plane, the anchor should be located at the midpoint of foot-
print to prevent the anchor from penetrating into the articu-
lar cavity or into the lateral cortex of the fibula. (vi) The
length and quality of ATFL should be determined during the
operation. If the repair conditions cannot be satisfied, the lig-
ament should be reconstructed or the approach should be
changed to that of the Broström-Gould procedure
31
.
(vii) Strength of ATFL fixation should be confirmed under
the arthroscopy before ring suture and tight suture to pre-
vent tear or fixation failure of ATFL during the suture pro-
cess. (viii) When using the suture hook to suture the ring of
ATFL, it is necessary to select a position of good quality
to prevent the tear of ATFL in the process of stitching
and knotting. (ix) Knotting should be carried out under
the supervision of arthroscopy to ensure the intensity and
effect of ligament suture. It is required to do standardized
rehabilitation exercises to prevent joint stiffness and varus
limitation.
Surgical Advantages
Although the traditional open operation can accomplish
direct ATFL repair, it cannot be used to deal with lesions in
the joint, such as cartilage injury or the hyperplasia of syn-
ovium. Compared with the traditional open surgery, arthro-
scopic surgery has the following advantages: (i) There is a
small incision, without wound complications, which can
greatly evaluate the situation of the ankle and ATFL. Besides,
accurate treatment can be performed. (ii) The lateral joint
capsule of the ankle cannot be injured in the procedure,
protecting the proprioceptor on the ankle capsule, which is
beneficial to the recovery of proprioceptive function after the
surgery. (iii) Nutritional vessels on ATFL are protected in
arthroscopic surgery, which is beneficial for the recovery of
the ligament and tendon–bone healing after surgery
32
.
(iv) The anatomical repair of ATFL is realized without affect-
ing the range of motion of the ankle and subtalar joint.
(v) Operating in the safe zone is preferred as it does not
affect the mobility of the ankle and the subtalar join
33
.
(vi) Suture intensity and fixation effect of ATFL can be
observed under the arthroscopy. (vii) Hospital stays are short
and function recovers well. The average postoperative hos-
pital stay of 37 patients was only 3.77 days, which was
significantly shorter than that of traditional postoperative
in-hospital recovery
34
. Regarding the therapeutic effect on
this group, the ankle pain disappeared completely, and the
ankle-inverted stress tests were negative. The anterior
drawer tests of the ankle were negative. The range of
motion of the patients was good. All patients returned to
normal gait. There was no mechanical instability or symp-
tomatic instability of the ankle.
Limitations
There are, however, some limitations to this procedure: (i) It
requires the operator to have a good arthroscopic technique
and related anatomical knowledge; (ii) The criteria of ana-
tomical repair or ligament reconstruction or superimposed
suture of extensor retinaculum in ATFL were mainly based
on varus stress test, drawer test, and operator experience, but
there was a relative lack of objective indexes; (iii) This study
is a retrospective study and thus lacked a control group.
However, well-designed prospective comparative studies are
still needed to further confirm the long-term functional out-
comes of this procedure.
Conclusions
Arthroscopic anatomical repair of ATFL for CLAI can
achieve accurate ligament anatomical repair. The surgical
trauma is small and the effect is reliable. In addition, the
medium- and long-term function is satisfactory, and there-
fore it can be applied extensively in the clinic.
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