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Purpose: To compare clinical function after knot anchor versus knotless anchor repair of the anterior talofibular ligament (ATFL) in patients with chronic lateral ankle instability., Methods: All patients who underwent arthroscopic surgical ATFL repair using knot or knotless suture anchors were included in this study. Functional scores (American Orthopedic Foot and Ankle Society (AOFAS), Karlsson score and Tegner activity scores) and magnetic resonance imaging (MRI) were used to evaluate the ankle with a follow-up of at least 2 years., Results: A total of 52 patients with chronic ankle instability were included in this study. Among these patients, 23 patients underwent one knot anchor repair procedure (Group A), and the other 29 patients underwent one knotless anchor repair procedure (Group B). At the final follow-up, there were no significant differences between Group A and Group B regarding the AOFAS score (89 ± 9 vs 84 ± 11; ns), Karlsson score (82 ± 14 vs 75 ± 18; ns), or Tegner activity score (4 ± 1 vs 4 ± 2; ns). There also were no significant differences in the mean ATFL signal-noise ratio (SNR) value (7.5 ± 4.4 vs 7.3 ± 2.9; ns) or ATFL angle (82° ± 7° vs 84° ± 9°; ns) between the groups., Conclusion: When compared with knot repair, knotless repair of the lateral ankle ligament produced similar functional outcomes., Level of Evidence: III.

Purpose: The aim of this study was to compare long-term outcomes after anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) repair and reconstruction at 5-10 years after surgery., Methods: Forty-five patients who underwent surgical repair or reconstruction of both ATFL and CFL were retrospectively investigated in this study. American Orthopedic Foot and Ankle Society (AOFAS), Karlsson Score, and Tegner activity scale were used to evaluate the ankle function at a follow-up of 5-10 years. Ultrasound examination was used to evaluate the ATFL and CFL, and MRI was used to evaluate the cartilage., Results: At final follow-up, no patient had recurrent ankle instability. There were no significant differences in AOFAS (92.6 ± 6.5 vs 89.6 ± 3.4; n.s.) or Karlsson Score (93 ± 8.2 vs 90.6 ± 5.0; n.s.) between the reconstruction group (twenty patients) and the repair group (twenty-five patients) postoperatively. There were also no significant differences in activity level as measured by the Tegner activity score (6 (range 4 to 8) vs 6 (range 5 to 7); n.s.). Five patients in the reconstruction group complained of some tightness of the ankles. Ultrasound showed the reconstructed ligaments maintained good continuity and were thicker than the repaired ligaments., Conclusion: Patients in both the repair and the reconstruction cohort had high patient satisfaction with the outcomes and high function and activity levels that indicated recreational sports participation over a long period., Level of Evidence: III.

Purpose: To compare the function and activity level after one-anchor repair versus two-anchor repair of the anterior talofibular ligament (ATFL) in patients with chronic lateral ankle instability., Methods: All patients who underwent arthroscopic surgical ATFL repair using suture anchors were included in this study. The American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (Karlsson score) and Tegner activity score were used to evaluate ankle function at a follow-up of a minimum of 2 years. A magnetic resonance imaging (MRI) scan was performed to evaluate the repaired ATFL., Results: A total of 51 patients with chronic ankle instability were included in this study. Among them, 20 patients accepted a one-anchor repair procedure (one-anchor group), and the other 31 patients accepted a two-anchor repair procedure (two-anchor group). At the final follow-up, there was no significant difference in the AOFAS score between the one-anchor group and the two-anchor group (90 ± 9 vs 91 ± 10; ns). However, the mean Karlsson score of the two-anchor group (88 ± 12) was significantly higher than that of the one-anchor group (80 ± 14) (p = 0.04). There was a significant difference in activity level as measured by the Tegner activity score (5 ± 1 vs 4 ± 1; p < 0.001) between the two-anchor group and the one-anchor group after surgery. Patients in the two-anchor group (68%) had a significantly higher percentage of sport participation compared to those in the one-anchor group (30%) (p = 0.01)., Conclusion: Compared with a one-anchor repair, a two-anchor repair of the lateral ankle ligament produced better functional outcomes. Arthroscopic ATFL repair with two anchors provided a minimally invasive technique with a higher rate of return to sports than repair with one anchor. The present study showed its clinical relevance by maintaining the advantage of ATFL repair using two anchors regarding the clinical function., Level of Evidence: III.

Purpose: To assess the impact on ankle stability after repairing the ATFL alone compared to repairing both the ATFL and CFL in a biomechanical cadaver model., Methods: Ten matched pairs of intact, fresh frozen human cadaver ankles (normal) were mounted to a test machine in 20.0° plantar flexion and 15.0° of internal rotation. Each ankle was loaded to body weight and then tested from 0.0° to 20.0° of inversion. The data recorded were torque at 20.0° and stiffness, peak pressure and contact area in the ankle joint using a Tekscan sensor, rotation of the talus and calcaneus, and translation of the calcaneus using a three-dimensional motion capture system. Ankles then underwent sectioning of the ATFL and CFL (injured), retested, then randomly assigned to ATFL-only Broström repair or combined ATFL and CFL repair. Testing was repeated after repair then loaded in inversion to failure (LTF)., Results: The stiffness of the ankle was not significantly increased compared to the injured condition by repairing the ATFL only (n.s.) or the ATFL/CFL (n.s.). The calcaneus had significantly more rotation than the injured condition in the ATFL-only repair (p = 0.037) but not in the ATFL/CFL repair (n.s.). The ATFL failed at 40.3% higher torque than the CFL, at 17.4 ± 7.0 N m and 12.4 ± 4.1 N m, respectively, and 62.0% more rotation, at 43.9 ± 5.6° and 27.1 ± 6.8°, respectively., Conclusions: There was a greater increase in stiffness following combined ATFL/CFL repair compared to ATFL-only repair, although this did not reach statistical significance. The CFL fails before the ATFL, potentially indicating its vulnerability immediately following repair., Level of Evidence: III, case-control therapeutic study.