C h ro n i c L a t e r a l A n k l e

Instability
Can We Get Even Better with Surgical
Treatment?

Jose Antonio Veiga Sanhudo, MD, PhDa,*, Eric Ferkel, MD

b
,
Kepler Alencar Mendes de Carvalho, MDc

KEYWORDS
 Ankle sprains  Ankle instability  Ankle reconstruction  Chronic instability
 Tendon augmentation

KEY POINTS
 Repetitive ankle sprains can lead to lateral ligament attenuation. “Laxity” and “giving way”
are symptoms indicators of ankle instability.
 Lateral ankle ligament surgeries can be performed through an open approach, arthro-
scopically, arthroscopic-assisted, or percutaneously.
 The anatomic ankle reconstruction technique described by Broström is renowned for its
excellent outcomes and high rate of return to sports.
 In skilled hands, arthroscopy-assisted or fully arthroscopic ligament reconstruction
carries a high rate of good and excellent outcomes and returns to sports.

INTRODUCTION

Ankle sprains are the most common injuries in sports and are always a cause for
concern because up to 74% of patients develop residual symptoms and many
develop chronic ankle instability (CAI).1 Despite the high prevalence of this injury, its
treatment remains controversial, and many patients neglect its severity, returning to
physical activity within a few days, increasing the chance of another sprain. Up to
34% of patients will have another sprain of the same ankle within 3 years.2,3 Repetitive
ankle sprains can lead to lateral ligament attenuation and an ever-increasing sensation
of “giving way.” “Laxity” is observed on physical examination, whereas “giving way” is

a
Foot & Ankle Department, Hospital Moinhos de Vento, Avenida Juca Batista 8000, 18 Porto
Alegre RS, Brazil CEP 91781-200; b Southern California Orthopedic Institute, 6815 Noble
Avenue, Suite 200, Van Nuys, CA, USA; c Department of Orthopedics and Rehabilitation, Uni-
versity of Iowa, Carver College of Medicine, Iowa City, IA, USA
* Corresponding author.
E-mail address: sanhudotraumato@gmail.com

Foot Ankle Clin N Am 28 (2023) 321–332

https://doi.org/10.1016/j.fcl.2023.01.004 foot.theclinics.com
1083-7515/23/ª 2023 Elsevier Inc. All rights reserved.

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322 Veiga Sanhudo et al

the symptom described by the patient. Both are indicators of ankle instability. These
findings are associated with mechanical and functional instability, decreased perfor-
mance in recreational and occupational activities, decreased global and regional func-
tions, and impairment of quality of life.1–5
Although ankle instability is divided into mechanical and functional, both usually
coexist. In classic functional instability, a patient with minimal laxity complains of
the ankle giving way and reports a history of several previous sprains. The factors
associated with functional instability include proprioceptive deficits, decreased neuro-
muscular control, loss of evertor strength, tight gastrocnemius–soleus complex, and
decreased postural control. Hindfoot varus, midfoot cavus, and ligamentous laxity
are predisposing factors for a lateral ankle sprain. Combining one or more of these fac-
tors with functional instability often results in an initial sprain followed by subsequent
episodes of recurrence. Chronic lateral ankle instability is usually the result of an un-
treated or inadequately treated sprain. However, it is still possible that even after an
appropriately treated sprain, the ankle cannot recover its preinjury function and will
develop sequelae, including chronic instability. Once established, CAI leads to a
feeling of giving way with decreased performance and long periods of inactivity after
each injury. Additionally, chronic instability can lead to chondral damage intra-
articularly, which can predispose a patient to tibio-talar joint arthritis.
Most experts agree that conservative treatment is the modality of choice initially af-
ter an acute ankle sprain, especially when it is the first such episode. However, the ef-
fect of nonsurgical treatment on already established chronic instability has yet to
receive much research interest. However, there is a consensus that nonsurgical treat-
ment is more effective for patients with significant functional instability. The corner-
stone of ankle rehabilitation aimed at relieving symptoms and preventing future
sprains is a combination of kinetic chain strengthening, evertor strength training, pro-
prioceptive training, and lateral wedge insoles.6–8 When conservative treatment is not
effective, surgical treatment is indicated.

Surgical Treatment
The surgical techniques for treating chronic instability are divided into anatomic repair,
anatomic reconstruction with a graft, and nonanatomic reconstruction. Anatomic
repair is performed when the ligaments are in suitable condition to be restored without
using other tissues to replace them. In this technique, the torn ligaments are tightened
and repaired or reinserted into the fibula with anchors or tunnels to restore adequate
tension and joint stability. Anatomic ligament reconstruction uses autogenous or allo-
genic graft due to the poor quality of the native ligaments that are injured beyond a
point where primary repair is impossible. Nonanatomic reconstruction involves local
tendon transfer to provide joint stabilization.
Anatomic ligament reconstruction with a graft and nonanatomic reconstruction is
typically reserved for severe recalcitrant cases, patients with a significantly elevated
Body Mass Index (BMI), hindfoot varus malalignment, and long-standing instability
with comorbid ligament hyperlaxity.
Lateral ankle ligament surgeries can be performed through an open approach,
arthroscopically, arthroscopic-assisted, or percutaneously. The traditional open
approach for ankle ligament reconstruction involves larger or smaller incisions
depending on the chosen technique. The Broström procedure and its numerous mod-
ifications are the most frequently performed. Many surgeons consider arthroscopy to
be a helpful adjunct in identifying and treating intra-articular injuries but also the main
procedure for fully arthroscopic reconstructions. However, it should be considered
that fluid extravasation into the soft tissues may make it more challenging identifying

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 Chronic Lateral Ankle Instability 323

the soft tissue planes in open procedures after ankle arthroscopy.9 Although arthros-
copy is justified by many surgeons as the initial approach to identify any comorbid le-
sions, it is essential to remember that every patient undergoing ligament
reconstruction of the ankle must be initially investigated with plain radiography and
MRI. MRI will detect most of these associated findings before surgery. In addition, it
is estimated that iatrogenic injuries to the joint cartilage occur in 31% of procedures,
with 6.7% of cases considered severe lesions.10 A percutaneous approach to recon-
struction of the lateral ligamentous complex aims to reduce the procedure’s morbidity
and is usually indicated in the absence of ankle deformity. The technique uses radiog-
raphy instead of arthroscopy to find critical points for ligament stabilization. Arthros-
copy has been used to assist the procedure in selected cases.11–15

Anatomic Repair
The anatomic ankle reconstruction technique described by Broström is renowned for
its excellent outcomes and high rate of return to sports, even in the long term, with no
difference in results between male and female patients. Technical details, such as
imbrication and ligament fixation with or without anchors, vary among authors, and
there is no established superiority of any one technique.16–23 Bell and colleagues re-
ported 91% of excellent functional results with the Broström-Gould technique after
an average of 25 years of follow-up. Karlsson and colleagues achieved 87% good
to excellent outcomes using a similar surgical technique.16,17 Gould’s modification
of the original Broström technique with reinforcement of the extensor retinaculum,
described in 1966, is performed by many authors whenever possible because it in-
creases the strength of the repair by 60% and improves the contact area of the joint
surface but good outcomes can be achieved even without this modification.23,24

Anatomic and Nonanatomic Reconstruction

Before surgery, it is sometimes difficult to estimate the quality of the ligaments accu-
rately through physical examination and imaging, even with MRI. Stress radiography is
helpful in demonstrating lateral ligament competence but it cannot demonstrate the
quality of the tissue to be repaired. Therefore, the decision to migrate from an
anatomic repair to a reconstruction is, and can occasionally be, made intraoperatively.
In cases of severe and long-standing instability, generalized ligament hyperlaxity,
obesity, high-demand activity, hindfoot varus malalignment, revision of previous sur-
gery, and poor quality of the lateral ligaments, anatomic repair may be impossible or
insufficient. In these cases, reconstruction with tendon augmentation is the alternate
choice (Fig. 1). However, this technique has the disadvantage of sacrificing a healthy
tendon as a graft. When the peroneus brevis is used, it has been shown to lead to a
loss in eversion strength, as well as prolonged operative times. Coupled with the
need for bone tunnels and a donor site approach, this has been shown to increase
the morbidity of the procedure and increase the chance of joint stiffness and degen-
erative joint changes.25–27
The Evans, Christmas-Snook, and Watson-Jones techniques are the most common
approaches in this category.25–27 The Watson-Jones procedure, in which the pero-
neus brevis tendon is passed through drill holes in the lateral malleolus and the
neck of the talus, provides good long-term outcomes. Nevertheless, cutaneous nerve
injury and recurrent instability are expected in 18% of cases.27
The procedure described by Evans is technically more straightforward than the
traditional Watson-Jones ligament reconstruction because only part of the distally
attached peroneus brevis graft is passed through a single oblique drill hole in the distal
fibula. However, the site of fixation is not anatomic.25 In this technique, the peroneal

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324 Veiga Sanhudo et al

Fig. 1. Reconstruction of the ATFL and the CFL with peroneus brevis graft. Intraoperative
images: (A) visualization of the injury degree level, (B) location and separation of the per-
oneus brevis and peroneus longus tendons, (C) passage of the peroneus brevis tendon
through the peroneal tunnel, and (D) final reconstruction of the ATFL and CFL.

tendon graft is positioned between the attachments of the anterior talofibular ligament
(ATFL) and the calcaneofibular ligament (CFL) and does not anatomically reconstitute
the continuity of either.28 The technique stabilizes the ankle and subtalar joint and re-
stricts ankle inversion in the short term. However, studies show that there is a loss of
efficiency in the long term, leading to inferior clinical outcomes compared with
anatomic reconstruction.25,28 Complications of the Evans technique are not uncom-
mon. They include persistent swelling, decreased range of motion, persistent insta-
bility sensation, or a “too tight” repair feeling, leading 50% or more of patients to
classify their outcome as unsatisfactory and report difficulty returning to their preinjury
level of sports activity.29,30 The Evans technique is also used as augmentation in com-
bination with the Broström-Gould repair, with some studies describing good results
and significant functional improvement.31–36 Anatomic reconstruction using autolo-
gous free peroneus brevis or semitendinosus grafts aims to preserve the advantages
of tendon reinforcement (greater strength) with a lower risk of decreased mobility.37,38
The Chrisman-Snook technique consists of using a split peroneus brevis graft,
routed through bone tunnels in the fibula and calcaneus, to reconstruct the lateral lig-
aments. The procedure is not technically simple but it does provide good long-term
outcomes and is an alternative for patients with low-quality connective tissue.

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 Chronic Lateral Ankle Instability 325

Nevertheless, one should be aware of the higher risk of incisional complications, sural
nerve injury, a “too tight” repair feeling, and persistent instability with a “giving way”
sensation.26,39–41
The use of an allograft is intended to reinforce the ligament reconstruction. The in-
dications are the same as for an autograft but without the inconveniences of sacrificing
a healthy structure and increasing operative time. This technique is advantageous in
cases of previously failed reconstruction, mainly when an autologous graft was
used. The use of nonautologous tissue, however, carries the disadvantages of a
greater risk of local reaction and longer healing time.42 Li and colleagues found in a
systematic review and meta-analysis of outcomes after allograft reconstruction in
patients with CLAI that there was an average American Orthopaedic Foot & Ankle
Society (AOFAS) scores improved from 55.4 to 91.9, which was a 40% improvement.
An 80% of the pooled proportion of patients returned to sports after surgery, and the
total risk of recurrent instability after surgery was only 6%. Furthermore, no graft rejec-
tion was reported in any of the studies reviewed (Li H, Song Y, Li H, Hua Y. Outcomes
After Anatomic Lateral Ankle Ligament Reconstruction Using Allograft Tendon for
Chronic Ankle Instability: A Systematic Review and Meta-analysis. J Foot Ankle
Surg. 2020;59(1):117 to 124. https://doi.org/10.1053/j.jfas.2019.07.008). Open or
percutaneous anatomic reconstruction, using semitendinosus or posterior tibial allo-
graft tendon, attached with bioabsorbable tenodesis screws, yields good functional
outcomes.43–45 Dierckman and Ferkel reported their results of this technique on 31 pa-
tients (Dierckman BD, Ferkel RD. Anatomic Reconstruction with a Semitendinosus
Allograft for Chronic Lateral Ankle Instability. Am J Sports Med. 2015;43(8):1941-
1950. https://doi.org/10.1177/0363546515593942). The authors found that 20% of
patients with CLAI required allograft augmentation in addition to a direct primary
repair. In their retrospective review, 100% of patients were completely satisfied at
an average follow-up of 38 months. Results of Broström-Gould ligament repair versus
anatomic reconstruction with a semitendinosus allograft demonstrated no difference
in outcomes after a mean 2 years of follow-up.46

Suture Tape Augmentation

Immediately after lateral ligament reconstruction, the strength of the repaired liga-
ments is still limited, making cast or boot immobilization mandatory and preventing
earlier rehabilitation. The use of tape augmentation in Broström-type ligament recon-
struction aims to increase primary stability to the lateral ligaments, especially in pa-
tients with long-standing instability, obese patients, and high-performance athletes.

Fig. 2. Lateral ankle anatomic reconstruction using the autologous Gracilis tendon plus tape
reinforcement. Intraoperative images: (A) location of the insertion point in the Fibula, (B
and C) fibular stem tensioning thread, and (D) final reconstruction view (Gracilis tendon
plus tape reinforcement).

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326 Veiga Sanhudo et al

Reinforcing the reconstruction with suture tape may allow for a shorter period of
immobilization, permitting earlier, more intense functional rehabilitation and an earlier
return to sports activities (Fig 2). However, the biomechanical consequences and the
possibility of foreign body granulomatous reaction to placement of this inelastic device
are still unknown.47–53
Case series have reported good outcomes with suture tape. Xu and colleagues
recently compared modified Broström repairs with and without suture tape augmen-
tation, with at least 2-year follow-up (Xu D-L, Gan K-F, Li H-J, et al. Modified Broström
Repair With and Without Augmentation Using Suture Tape for Chronic Lateral Ankle
Instability. Orthop Surg. 2019;11(4):671-678. https://doi.org/10.1111/os.12516). This
study included 25 patients undergoing modified Broström repair with suture tape
augmentation and 28 patients with isolated modified Broström repair. Both groups
achieved satisfactory outcomes and significant improvements in terms of pain and
functional outcome scores. There were no statistical differences between the 2 groups
when comparing the range of motion, Visual Analog Scale (VAS), AOFAS scores, and
radiologic outcomes. However, when comparing the Foot and Ankle Ability Measure
surveys, the suture tape augmentation group had significantly better scores than
the isolated Broström repair for the Sport (87.1 vs 78.2) and Total (93.1 vs 90.5)
outcome surveys.
Nevertheless, other comparative studies have shown that superior results may be
achieved only in the first weeks after surgery, with similar long-term outcomes. The
possibility of more intense early rehabilitation is desirable for high-performance ath-
letes but one must consider the approximately 30% increase in the cost of the proced-
ure. There also is a greater risk of complications involving the peroneal nerve and
tendons due to local tissue irritation.51

Arthroscopic and Arthroscopy-Assisted Reconstruction

CAI can be associated with many intra-articular conditions, including impingement,
chondromalacia, osteochondral lesions of the talus, loose bodies, and osteophytes.
These conditions can contribute to the clinical picture and surgical indication and, if
not addressed, can be a cause of residual symptoms leading to less favorable out-
comes after ligament stabilization.1,2 Comorbid extra-articular lesions, such as pero-
neal tendinopathy, are not routinely treated arthroscopically, and surgeons should be
aware of this limitation.54,55 Arthroscopy can be helpful as a diagnostic and therapeu-
tic tool for associated injuries alone but there are described techniques for fully arthro-
scopic ligament reconstruction (Fig 3). Interest in arthroscopic reconstruction stems
from its minimally invasive nature and the possibility of reduced morbidity and faster
recovery. In skilled hands, arthroscopy-assisted or fully arthroscopic ligament recon-
struction carries a high rate of good and excellent outcomes and returns to sports,
with no significant increase in complications, even in the presence of ligament hyper-
laxity.56 Arthroscopic techniques involve “Arthro-Broström” type anatomic repairs and
autologous or allogeneic graft reconstructions.47,57–66 These reconstructions require
high arthroscopic skill to minimize the risk of iatrogenic injury to the cartilage. All carry
a risk of complications, mainly neurovascular injury, due to the creation of portals and
the passage of sutures, even under direct arthroscopic visualization. Incisional com-
plications, tendon injuries, deep venous thrombosis, and recurrence of instability
have also been described.57–66 The higher cost of the procedure due to the use of
more sophisticated instruments and materials must also be considered. Compared
with the open technique, arthroscopic lateral ligament repair is technically more
demanding. However, it leads to better AOFAS scores, less pain at 6 and 12 months,
postoperatively, and earlier weight-bearing after surgery. Nonetheless, there does not

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 Chronic Lateral Ankle Instability 327

Fig. 3. Arthroscopic Bröstrom and treatment of osteochondral lesion of the talus (OLT). In-
traoperative images: (A) Visualization of the injury degree level and arthroscopic loose body
removal, (B) OLT treatment, (C) arthroscopic Bröstrom, and (D) external view.

seem to be any difference in long-term outcomes. Operative time and complication

rate are statistically comparable.67–71

Comparative Studies Including All Techniques

Cao and colleagues performed a meta-analysis to compare the outcomes of different
surgical techniques for treating CAI. Seven randomized clinical trials were included.
The authors could not conclude the best surgical option for managing CAI due to a
lack of statistical significance and low methodological quality. However, based on
the existing evidence, Broström-type ligament reconstruction and its modifications
lead to outstanding outcomes. Nonanatomic reconstructions should be used spar-
ingly due to poor clinical outcomes and a high rate of sprain recurrence; nonanatomic
reconstructions increase subtalar stiffness.72 Lu and colleagues conducted a system-
atic review and meta-analysis to determine the overall effectiveness of various lateral

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328 Veiga Sanhudo et al

ankle ligament reconstruction methods for chronic ankle ligament instability and found
that, across 12 studies including 476 patients, good and excellent results were ob-
tained in 85% of the cases.73

SUMMARY

During the past several decades there has been a great deal of study involving
advanced techniques involved in the treatment of chronic lateral ankle ligament insta-
bility; however, open anatomic Broström-Gould ligament reconstruction remains the
gold standard as a technically simple, low-cost procedure with a high rate of good
and excellent outcomes and a high percentage of return to sports. Using a free autol-
ogous graft is an excellent option for ligament attenuation unsuitable for primary su-
tures because it carries the benefits of reinforcement while minimizing joint
stiffness. Allograft reconstructions are indicated in revision cases, especially those
with a history of failed autograft reconstruction. Arthroscopy is an excellent adjunct
for joint inspection and identification of associated lesions and should be used before
ligament reconstruction; however, fully arthroscopic reconstructions are also
becoming increasingly popular due to published results. Suture-tape augmentation
may be a useful adjuvant for a specific patient population, despite the increased costs
of the procedure. Specific indications include patients where early rehabilitation is
imperative, such as professional athletes, but its long-term benefits are yet to be
proven. As long as the limitations and indications of each treatment option for chronic
instability are followed, excellent outcomes can be expected in most cases.

CLINICS CARE POINTS

 The decision to migrate from an anatomic repair to a reconstruction can occasionally be

made intraoperatively.
 In severe and long-standing instability, reconstruction with tendon augmentation could be
necessary.
 The use of tape augmentation in Broström-type ligament reconstruction aims to increase
primary stability of the lateral ligaments.
 Arthroscopy can be helpful as a diagnostic and therapeutic tool for associated injuries alone.
 Open anatomic Broström-Gould ligament reconstruction remains the gold standard as a
technically simple with a high rate of good and excellent outcomes and a high percentage
of return to sports.

DECLARATION OF INTERESTS

The authors have nothing to disclose.

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