Clinicians › Ankle

Ankle arthroscopy

122 citationsUpdated Sep 2026

Overview

Ankle arthroscopy is a relatively new and dynamic surgical tool that offers decreased morbidity and faster recovery times compared with open arthrotomy [12]. When used for appropriate indications, the procedure yields good results [1], and adequate evidence-based literature supports the technique for most generally accepted indications [2]. The number of indications for anterior ankle arthroscopy is rising, with open surgery increasingly replaced by arthroscopic approaches for anterior pathology [9]. Posterior ankle arthroscopy serves as a powerful diagnostic and therapeutic modality, covering diagnostics, surgical techniques, complications, geographical differences, and future developments [7, 8, 10]. Arthroscopic treatment of ankle instability is emerging as a potential gold standard technique, offering the advantage of addressing both instability and associated intra-articular pathology in a single procedure with excellent results [175].

The procedure is safe, with a low overall complication rate [14], and arthroscopic treatment of anterolateral ankle soft-tissue impingement is very safe when indicated [28]. Two-millimetre diameter operative arthroscopy is safe and effective, holding the potential to make the procedure less invasive and more accessible [21]. Combining ankle arthroscopy with a modified Brostrom procedure provided significantly improved ankle hindfoot scores at an average of 35 months follow up [34]. Posterior ankle arthroscopy is a safe and effective surgical procedure for posterior ankle impingement [37]. Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise, though further evaluation is required to determine indications for repair versus reconstruction and to obtain information on long-term outcomes [31].

Surgical practices in ankle instability are heterogeneous [19], and operative procedures focusing only on part of the pathology should be approached with caution until all deficiencies are defined [4]. Ankle arthroscopy was performed more frequently in female patients and most commonly in patients younger than 50 years, with a significant increase in its use for lateral ankle instability management [3]. Fair-quality evidence exists in support of open operative treatment of chronic ankle instability [11]. It is important to remember the potential complications and try to avoid them when performing ankle arthroscopy [13]. With sound knowledge regarding the indications, merits, and potential risks of new techniques, they will be powerful tools in foot and ankle surgery [15]. Ankle arthroscopy has become a very handy tool for helping patients alleviate ankle pain as long as the indication is fulfilled [27]. Further studies are needed in the area of ankle arthroscopy indications [2].

Anatomy & Pathophysiology

Bony Anatomy

The ankle mortise is formed by the tibial plafond, medial malleolus, and lateral malleolus, articulating with the dome of the talar body [87]. The talar dome is wider anteriorly and narrower posteriorly [87]. During motion from plantar flexion to dorsiflexion, the ankle mortise widens 1 to 1.5 mm [87]. Consequently, medial and superior clear spaces appear wider with the foot in plantar flexion [87]. The distal fibula features a convex medial surface that articulates with the concave incisura fibularis of the distal lateral tibia [87]. The fibula rotates approximately 2 degrees within the incisura during ankle motion and ambulation [87]. Ankle dorsiflexion results in external rotation and proximal translation of the fibula [87].

Radiographic parameters define normal alignment. The talocrural angle is approximately 83 degrees and symmetrical with the contralateral ankle [96]. The medial clear space should be less than 5 mm and no more than 2 mm greater than the tibiotalar clear space [96]. The tibiofibular clear space 10 mm above the joint line should be greater than 5 mm [96]. The tibiofibular overlap 10 mm above the joint line should be less than 5 mm on AP view and less than 1 mm on the mortise view [96]. Plantar flexion of the ankle produces changes in radiographic measurements of the medial clear space [108]. The size of the medial clear space more than doubles depending upon the rotational position of the limb [96]. There is a significant increase in medial clear space with ankle plantarflexion [96].

Ligamentous Anatomy

The lateral ligament complex consists of three primary structures. The anterior talofibular ligament (ATFL) originates from the anteroinferior aspect of the lateral malleolus, 1 cm proximal to its tip, and extends to the lateral aspect of the talar neck [87]. The calcaneofibular ligament (CFL) extends from the tip of the lateral malleolus to the lateral aspect of the calcaneus [87]. The posterior talofibular ligament (PTFL) extends from the posterior lateral malleolus to the posterolateral talus [87]. The ATFL is the weakest ankle ligament, while the PTFL is the strongest [87]. These lateral ligaments function as restraints to varus and inversion forces at the ankle [87]. The distal tibiofibular joint and fibula provide stability against lateral talar translation [87]. The ATFL inferior fascicle is connected to the calcaneofibular ligament, whereas the ATFL superior fascicle is an intra-articular structure [157]. The accessory anteroinferior tibiofibular ligament is a normal anatomical finding that could lead to anterolateral impingement in cases with coexistent ankle instability [41].

The deltoid ligament complex comprises superficial and deep components. The deep deltoid ligament extends from the apex of the medial malleolus to the medial talar body, functioning primarily to resist lateral talar translation and external rotation [87]. The posterior deep deltoid is the most important component of the deltoid complex [87]. The superficial deltoid ligament extends from the distal medial malleolus to the navicular bone, sustentaculum tali of calcaneus, medial talus, and spring ligament, functioning primarily to resist valgus and eversion ankle forces [87]. The deltoid ligament consists of at most six bands, of which only three are constant: the tibionavicular ligament, tibiospring ligament, and deep posterior tibiotalar ligament [93]. The tibiocalcaneal portion of the superficial deltoid is the strongest component and resists eversion of the calcaneus [93]. The deep portion of the deltoid is organized into two short, thick, discrete bands: the anterior and posterior deep tibiotalar ligaments [93]. The deep posterior band comprises the largest band of the deltoid complex [93].

Biomechanical testing reveals distinct failure modes. The deep deltoid ligament has the highest load to failure at 713.8 N ± 69.3 compared with the lateral collateral ligaments [93]. The dominant mode of failure for the deep deltoid is an intrasubstance rupture near its talar insertion [93]. In contrast, the dominant mode of failure for the superficial deltoid is at its insertion on the anterior malleolus [93].

Neurovascular Anatomy

Key neurovascular structures are located in specific anatomical planes relative to the malleoli. The superficial peroneal nerve penetrates the deep fascia and lies subcutaneously 8 to 10 cm proximal to the tip of the lateral malleolus [91]. The anterior tibial artery can be palpated beneath the superior extensor retinaculum 4 to 5 cm proximal to the distal articular surface of the tibia [91]. The deep peroneal nerve accompanies the anterior tibial artery and lies between the tendons of the anterior tibial and extensor digitorum longus, usually just lateral to the artery [91]. The saphenous nerve is located just medial or posterior to the saphenous vein and in a slightly deeper plane 3 to 5 cm proximal to the tip of the medial malleolus [91].

Portal placement carries specific nerve injury risks. The structure at greatest risk of injury during placement of the anterolateral portal is the intermediate dorsal cutaneous branch of the superficial peroneal nerve [45]. The structures at greatest risk of injury during placement of the posterolateral portal are the sural nerve and the lesser saphenous vein [45]. The structures at greatest risk of injury during placement of the posteromedial portal are the tibial nerve and posterior tibial artery and veins [45]. An accessory incision for lateral ligament repair should not surpass 22 mm distance from the lateral malleolus in the anterior direction due to the risk of damaging the superficial peroneal nerve [95].

Pathophysiology of Instability

More than 75% of ankle ligament injuries involve the lateral ligament complex, particularly the ATFL and CFL [52]. Medial ligament injuries are usually seen in association with a fracture or joint injury [52]. In ankles with chronic ankle instability, a rupture or elongation of the ATFL was noted in 86% [26]. A rupture or elongation of the CFL was noted in 64% [26]. A rupture or elongation of the deltoid ligament was noted in 40% [26]. Cartilage damage was noted in 66% of ankles with lateral ligament injuries and in 98% of the ankles with deltoid ligament injuries [26]. Medial instability was presumed clinically in 38 patients but was actually detected in 54 patients arthroscopically [26].

The dynamic congruency of the joint, influenced by ligamentous integrity, remains the main anatomical component in mechanical ankle instability [90]. The greatest increases in laxity after sectioning the ATFL occurred in ankle positions and loads corresponding to common modes of injury [117]. Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus [145]. Abnormal internal rotation of the talus in patients with mechanical ankle instability was decreased after ankle lateral stabilization surgery [132]. The ATFL–PTFL angle decreases after ankle lateral stabilization surgery [152]. The number of mechanoreceptors was negatively correlated with ankle sensorimotor dysfunction in chronic ankle joint instability [128]. Distinct characteristics of the incisura fibularis morphology are associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement [129].

Pathophysiology of Fractures and Syndesmosis

Syndesmosis disruption occurs in up to 11% of all ankle injuries [45]. In rotational ankle fractures, 30% to 39% have a concomitant syndesmotic injury [45]. Osteochondral defects and other chondral injuries may be present in 57 to 90% of patients with ankle fractures [45]. Concomitant intra-articular injuries have been reported in up to 80% of patients with ankle fractures [73]. Osteochondral lesions were present in 26% of Weber B fractures, 24% of Weber C fractures, and 20% of isolated medial malleolar fractures [73]. Chondral lesions were identified in 78% of 116 patients with acute ankle fracture [73]. Talar dome chondral lesions were identified in 43% of patients with acute ankle fracture [73]. All patients with dislocations had a chondral lesion [73]. Patients with complete syndesmosis disruption and instability were more likely to have chondral injury [73]. Patients younger than 30 were less likely to have a chondral injury [73].

Post-operative kinematics and biomechanical stability are affected by syndesmotic integrity. The operative ankle exhibited greater syndesmosis length and altered kinematics compared to the healthy side during all tested activities after syndesmosis repair [92]. Isolated posterior malleolus osteotomy and isolated anterior inferior tibiofibular ligament and interosseous ligament rupture only partially increased fibular motion in dorsiflexion and plantar flexion [149]. The combination of posterior malleolus osteotomy and anterior inferior tibiofibular ligament and interosseous ligament rupture resulted in an unstable syndesmosis in all planes [149].

Iatrogenic Pathophysiology

The incidence of cartilage injury during ankle arthroscopy is high [17]. Severe cartilage damage was found in only 6.7% of ankle arthroscopies [17]. Of the cartilage injuries found, 78.2% were superficial and 21.8% were deep [17]. 65% of cartilage injuries were sustained during the therapeutic portion of the arthroscopic procedure, while 35% occurred during the portal creation portion [17].

Nerve injury is the most common complication related to ankle arthroscopic procedures [17]. Complications of arthroscopic ankle surgery using small joint instruments and contemporary noninvasive distraction techniques occur in about 5% to 7% of patients [45]. The most common complication of ankle arthroscopy is neurologic injury, occurring in approximately 80% of complications [45]. Approximately half of neurologic complications involve the intermediate dorsal cutaneous branch of the superficial peroneal nerve [45]. A synovial cutaneous fistula is a more common complication with ankle arthroscopy than with arthroscopy of other joints [45].

Classification

Ligamentous Pathology

Arthroscopy provides superior diagnostic accuracy compared to current imaging studies for the definitive assessment of ligament lesions in patients with chronic ankle instability [40]. An established arthroscopic classification of chronic anterior talofibular ligament (ATFL) lesions allows for the assessment of these ligaments and is helpful in determining the best surgical technique for stabilising the ankle [39]. Preoperative ankle arthroscopy reveals structural changes in 86% of ankles with rupture or elongation of the anterior talofibular ligament, 64% of ankles with rupture or elongation of the calcaneofibular ligament, and 40% of ankles with rupture or elongation of the deltoid ligament [26]. Arthroscopic evaluation frequently identifies pathology missed by clinical examination; medial instability was clinically presumed in 38 patients but was actually detected in 54 patients via arthroscopy [26]. The final diagnosis of chronic instability of the anterior syndesmosis can be made during arthroscopy of the ankle [22]. In contrast, grading the three major ligamentous complexes and individual ankle ligaments according to the Schneck grading system on 3 T MRI results in limited diagnostic reliability [160].

Osteochondral and Chondral Pathology

Ankle arthroscopy is a very effective method for the diagnosis of ankle osteochondral lesions (OLTs) and other intraarticular pathologies [188]. The Berndt and Harty classification system is primarily a radiographic staging system for osteochondral lesions of the talar dome [178]. Stage I is defined as a small compression fracture, stage II as incomplete avulsion of a fragment, stage III as complete avulsion without displacement, and stage IV as an avulsed fragment displaced within the joint [178]. An increase in the radiographic stage according to this system does not necessarily predict increasing fragmentation or loosening of the lesion arthroscopically [178]. For example, of eight radiographic stage IV lesions, four were considered grade I (intact, firm, shiny cartilage) on arthroscopic evaluation [178]. An international consensus has derived appropriate terminology for osteochondral lesions of the ankle [162]. In a cohort of 204 consecutive chronic lateral ankle instability patients, 22 were treated with osteochondral transplantation and 34 had chronic lateral ankle instability associated with multiple osteochondral lesions of the talus [196]. Limited medial osteochondral lesions of the talus associated with chronic ankle instability do not impact the results of endoscopic modified Broström ligament repair [196].

Diagnostic Utility and Trends

Ankle arthroscopy serves as a useful adjuvant tool to understand the severity and complexity of acute ankle fracture [30]. Recognition of the ankle fracture component is important as it may alter the surgical plan and postoperative management [70]. In a study of 116 consecutive patients undergoing acute ankle fracture open reduction internal fixation with concurrent arthroscopy, the presence of a dislocation at the time of injury, unstable syndesmosis injury, or deltoid ligament injury was recorded [85]. Anterior ankle arthroscopy was superior to MRI in detecting "web impingement" pathology of the ankle [33]. The number of indications for anterior ankle arthroscopy is rising, and open surgery is increasingly replaced by arthroscopic surgery [9]. The Diagnostic Ankle Arthroscopy Skills Scoring System was a valid measure to objectively assess trainees' ankle arthroscopy clinical knowledge and operative skills in a bioskills laboratory [143].

Clinical Presentation

Ankle arthroscopy has evolved from a diagnostic to a therapeutic tool, with adequate evidence-based literature supporting its use for most generally accepted indications [2]. Anterior procedures effectively treat impingement and osteochondral defects using dorsiflexion rather than routine distraction [113]. Arthroscopic surgery and tendoscopy are emerging for disorders of the posterior ankle, subtalar joint, and first metatarsophalangeal joint, offering diagnostic and therapeutic benefits while preserving the soft-tissue envelope more extensively than open surgery [106]. Utilization patterns indicate that ankle arthroscopy is performed more frequently in female patients and most commonly in those younger than 50 years, with a significant increase in its use for lateral ankle instability management [3].

Chronic Ankle Instability

Preoperative arthroscopy reveals essential information regarding ligament abnormalities and intra-articular pathologic conditions that would otherwise remain undetected in patients with chronic ankle instability [26]. In a series of 148 patients with symptomatic chronic ankle instability, rupture or elongation of the anterior talofibular ligament was noted in 86% of ankles [26], while rupture or elongation of the calcaneofibular ligament was noted in 64% [26]. Rupture or elongation of the deltoid ligament was observed in 40% of ankles [26]. Cartilage damage was present in 66% of ankles with lateral ligament injuries [26] and in 98% of ankles with deltoid ligament injuries [26]. Although lateral instability could be verified arthroscopically in 127 patients, medial instability was presumed clinically in 38 patients but was actually detected in 54 patients arthroscopically [26]. Arthroscopy plays a crucial role in the definitive assessment of ligament lesions, supplying far more accurate information than current imaging studies [40]. An arthroscopic classification of chronic anterior talofibular ligament lesions confirms the diagnostic role for arthroscopy and helps determine the best surgical technique for stabilising the ankle [39]. The endoscopic approach allows assessment of the ankle joint and treatment of associated intra-articular lesions in patients with chronic lateral ankle instability [25]. Anatomical reconstruction of the anterior talofibular ligament is a recommendable choice for treating functional ankle instability in cases with morphologic ligamentous abnormality [42]. Acute instabilities generally undergo conservative treatment, while chronic instabilities are better addressed with surgery, making ankle arthroscopy a mandatory tool for both diagnosis and treatment [69]. One in three patients with chronic lateral ankle instability has a cartilage lesion [71].

Anterolateral Soft-Tissue Impingement

Anterolateral soft-tissue impingement is a common cause of chronic pain after one or more lateral ankle sprains [154]. It is characterized by hypertrophic synovium, inflamed or enlarged capsular tissues, and scarring [154]. This condition occurs with or without associated lateral ankle instability [154]. The most common site is the superior portion of the anterior talofibular ligament [154], though impingement also occurs along the distal portion of the anterior-inferior tibiofibular ligament [154]. Patients typically report persistent anterolateral ankle pain with activity [154]. Physical examination notes well-localized tenderness at the anterolateral ankle joint [154]. A specific physical examination test involves reproduction of pain with plantar flexion of the ankle, followed by thumb pressure at the anterolateral ankle joint, and dorsiflexion of the ankle [154]. Conventional MRI has a reported sensitivity and specificity of less than 50% for this condition [154], whereas clinical examination has a reported sensitivity of 94% and specificity of 75% [154]. Good to excellent results have been reported in 80% to 95% of patients treated for anterolateral soft-tissue impingement [154].

Posterior Ankle Impingement

Treatment for posterior ankle impingement, including os trigonum syndrome, a prominent posterior talar process, or posterior process fracture, can be effectively achieved via posterior ankle arthroscopy [45]. Posterior ankle arthroscopy was effective in patients with residual symptoms after syndesmosis injury [23]. Posterior ankle endoscopy in the supine position is a safe and effective approach, particularly when concomitant anterior ankle pathology requires anterior arthroscopy [72]. The first prospective study to evaluate posterior ankle arthroscopy in an exclusively young population demonstrates promising outcomes, supporting its role in the management of posterior ankle pathology [5].

Acute Ankle Fractures and Syndesmosis

Ankle arthroscopy is increasingly used to assess for syndesmotic instability and osteochondral defects at the time of ankle fracture fixation [45]. It has the highest sensitivity and specificity for diagnosing syndesmotic injuries missed on plain and stress view radiographs [45]. Arthroscopic diagnosis of syndesmotic instability includes disruption of the deep portion of the posterior tibiofibular ligament, rupture of the interosseous ligament with a syndesmotic gap > 2 mm, or a fracture of the posterolateral portion of the tibial plafond [45]. Concurrent ankle arthroscopy at the time of open reduction and internal fixation provides better visualization and less disruption to surrounding soft tissues to view fracture reduction as well as intra-articular pathology, including osteochondral defects and loose bodies [45]. Ankle arthroscopy is essential for diagnosis and treatment, allowing for the evaluation of anatomic reduction and residual diastasis in syndesmosis instability [58]. Syndesmosis disruption is common and occurs in up to 11% of all ankle injuries [45]. Arthroscopy-assisted reduction in the management of isolated medial malleolar fracture has the potential to identify occult intraarticular lesions [127]. Various simultaneous intraarticular pathologies, which are difficult to diagnose by preoperative physical or radiological examination, are responsible for poor outcomes in ankle fractures [127].

Diagnostic Accuracy and Imaging Comparison

Anterior ankle arthroscopy is of great value in the diagnostic work-up and treatment, and was superior to MRI in detecting "web impingement" pathology [33]. Diagnostic arthroscopy is a useful adjunct for diagnosing consolidation in cases with equivocal imaging findings after tibiotalar arthrodesis [57]. Pre-operative 3.0-T MRI demonstrated excellent accuracy in the diagnosis of syndesmotic ligament tears and allowed for the visualization of individual structures [68]. Pathology diagnosed on pre-operative MRI correlated strongly with arthroscopic findings for syndesmotic ligament disruption [68]. The sensitivity of common clinical findings for lateral ankle ligament injuries increases in the delayed setting, resulting in improved diagnostic accuracy compared to the acute setting [124]. In the acute setting (0–2 days post-injury), pain and swelling might negatively affect the reliability of physical examination for lateral ankle ligament injuries [124].

Complications and Safety

When performing ankle arthroscopy, it is important to remember the potential complications and try to avoid them [13]. The incidence of cartilage injury during ankle arthroscopy is high, with severe damage found in only 6.7% of procedures [17]. Of the iatrogenic cartilage injuries found, 65% were sustained during the therapeutic portion of the procedure and 35% occurred during the portal creation portion [17]. The most common complication of arthroscopic ankle surgery is neurologic injury, accounting for approximately 80% of complications [45]. Approximately half of the neurologic injuries involve the intermediate dorsal cutaneous branch of the superficial peroneal nerve [45]. The structures at greatest risk of injury during placement of the posteromedial portal during posterior ankle arthroscopy are the tibial nerve and posterior tibial artery and veins [45]. It was recently suggested that a large number of complications in ankle arthroscopy can be contributed to the continuous distraction itself [61]. Working without distraction gives better access to anterior ankle pathology because it creates an anterior working space [61].

Investigations

General Diagnostic Utility: Preoperative ankle arthroscopy provides important insights into the causes and mechanisms of ankle instability and the resulting disability [26]. It reveals an essential amount of information regarding ligament abnormalities and intra-articular pathologic conditions that would otherwise have been undetected [26]. An arthroscopic classification of chronic anterior talofibular ligament (ATFL) lesions confirms the diagnostic role for arthroscopy in assessing the ligaments in patients with chronic ankle instability [39].

Cartilage and Intra-articular Lesions: The endoscopic approach allows assessment of the ankle joint and treatment of associated intra-articular lesions [25]. Ankle arthroscopy is a useful adjuvant tool to understand the severity and complexity of acute ankle fracture, including the identification of full-thickness talar cartilage lesions [85]. In ankles with deltoid ligament injuries, 98% had cartilage damage [26]. The presence of an osteochondral lesion had a negative effect on the overall result when compared to that of patients who underwent lateral ankle stabilization as an isolated procedure [213].

MRI: Preoperative MRI is a reliable and valid decision-making tool for the choice of surgical stabilization technique in patients with chronic lateral ankle instability [191]. Preoperative 3.0-T MRI demonstrated excellent accuracy in the diagnosis of syndesmotic ligament tears. For the anterior inferior tibiofibular ligament, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 87.5%, 100%, 100%, 71.4%, and 90.5% respectively [68]. For the posterior inferior tibiofibular ligament, these values were N/A, 95.2%, 0.0%, 100%, and 95.2% respectively [68]. For the interosseous tibiofibular ligament, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 66.7%, 86.7%, 66.7%, 86.7%, and 81.0% respectively [68]. MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time [209]. MRI can show osteophytes but is not very sensitive for soft-tissue impingement [104]. About 20% of athletes referred for MRI after suffering an acute ankle sprain had evidence of a syndesmatic injury regardless of lateral ligament involvement [181]. More than half of athletes referred for MRI after suffering an acute ankle sprain had evidence of any lateral ligament injury without syndesmotic involvement [181].

Plain radiography: Traditional radiographic measurements should not be relied on solely for determining if the syndesmosis is intact and the ankle mortise is stable [195]. In cases of symptomatic posterior ankle impingement, a PIM view is advised to be used instead of or in addition to the standard lateral view for detection of posterior talar pathologic conditions [207].

Other Considerations: In one study, 58% of patients with anterior ankle impingement had an associated diagnosis, which changed the surgical plan in 33% [104]. An accessory anteroinferior tibiofibular ligament, although a normal anatomical finding, could lead to anterolateral impingement in cases with coexistent ankle instability [41]. Simultaneous arthroscopy, independent of pre-operative MRI findings, appears reasonable in highly active patients with acute, isolated and unstable syndesmotic injuries [156].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, or NSAIDs. However, the literature notes that arthroscopic debridement of the arthritic ankle must be used judiciously with realistic expectations, as it provides only short-term relief in advanced cases and is not recommended in most instances [136].

Operative

Indications: Ankle arthroscopy is a mandatory tool for both the diagnosis and treatment of chronic instabilities [69]. It is recommended before open lateral ankle ligament surgery because concomitant intraarticular pathologic processes are often associated with chronic ankle instability [43]. For anterior ankle impingement, arthroscopic removal of bone spurs and scar tissue yields excellent or good results in approximately 75% of cases when joint-space narrowing is absent [45]. In patients with chronic syndesmosis injuries, arthroscopic debridement of associated intraarticular pathology can be performed without screw fixation if there is no lateral displacement of the talus [73].

Surgical Approach / Technique: The no-distraction and dorsiflexion technique is key to the evolution of ankle arthroscopy, allowing for advanced third-generation procedures and reducing morbidity compared to routine distraction [100]. Two-millimetre diameter operative arthroscopy may make the procedure less invasive and more accessible [21]. Medial and lateral antero-superior ancillary portals are valuable for addressing repair procedures in ankle joint compartments blind to traditional access [102]. Recent advancements in in-office needle arthroscopy technology enable procedures under local anesthesia in the office setting [192]. Posterior ankle arthroscopy is a safe and effective procedure for posterior ankle impingement [37]. Performing posterior endoscopy in the supine position allows treatment of both posterior impingement and concomitant anterior pathology without changing patient position [72].

Implant Selection: For chronic lateral ankle instability, both open and arthroscopic all-inside anatomic reconstruction with autologous gracilis tendon restore ankle stability [198]. An all-arthroscopic technique for anatomic reconstruction leads to good clinical results [105]. Arthroscopic all-inside anterior talo-fibular ligament repair with suture augmentation provides excellent results when ligament tissue remnant quality is poor [187]. Arthroscopic anterior deltoid plication with a bone anchor effectively controls residual talar anterior translation after lateral ligament repair [208]. Surgeons may consider novel techniques such as suture anchors, synthetic augmentation, and all-arthroscopic stabilization for lateral ankle instability [168]. However, thermal capsular shrinkage has sparse supporting evidence, resulting in a grade C recommendation [43].

Alignment / Balancing Strategy: Surgically, arthroscopic and open repair techniques appear biomechanically equivalent in their ability to restore ankle stability, although sufficient evidence is lacking to deem any particular procedure superior [67]. Arthroscopic ankle stabilisation repair and reconstruction techniques hold promise but require further evaluation to determine indications for repair versus reconstruction and to obtain long-term outcome data [31].

Adjuncts: Concurrent ankle arthroscopy at the time of open reduction and internal fixation (ORIF) of ankle fractures provides better visualization and less soft tissue disruption to view fracture reduction and intra-articular pathology, including osteochondral defects and loose bodies [45]. Arthroscopic evaluation before fixation can detect chondral injuries and latent syndesmosis injuries [73]. A meta-analysis indicates that functional outcomes are better after arthroscopically assisted ORIF than conventional open reduction [73]. However, fair-quality evidence supports arthroscopy for detecting intraarticular injuries, but there is insufficient evidence for improved functional outcomes, reduced complication rates, or shorter operative time [73]. Fuchs et al. found no statistically significant improvement in unstable ankle fractures with concomitant arthroscopy, but also no increased complications [73]. Supplementing ankle fracture fixation with arthroscopy carries a grade I (incomplete) recommendation [73].

Setting of Care: Average operative time increases by only 15 minutes when supplementing ankle fracture fixation with arthroscopy [73]. A driving abstinence of two weeks is necessary after right-sided ankle arthroscopy [62].

Other Considerations: Primary arthroscopic reduction of talar neck fractures has been reported, with Wagener et al. achieving primary reduction in six of seven patients [73]. Patients with chronic widening of the syndesmosis can benefit from arthroscopic debridement and percutaneous screw placement across the syndesmosis after reduction [73]. Low-flow arthroscopy allows direct visualized debridement of ballistic missile tracts, decreasing the risk of infection and retained foreign bodies compared to open arthrotomy [189]. The modified Broström procedure combined with ankle arthroscopy produces satisfactory outcomes in patients with chronic ankle instability accompanied by intra-articular symptoms [55]. The endoscopic approach for lateral ligament reconstruction allows assessment of the ankle joint and treatment of associated intra-articular lesions [25]. Although only fair-quality evidence supports open operative treatment of chronic ankle instability, systematic reviews reassure clinicians of current practices [11]. Arthroscopy did not decrease the rate of reoperations for lateral ligament reconstruction but was associated with a lower rate of ankle arthrodesis as a second procedure and lower complications [43].

Arthrodesis: Arthroscopic ankle arthrodesis has been performed with generally favorable union rates [159]. One study of 101 ankles in 97 patients, reviewed on average 86 months postoperatively, demonstrated that 95% of ankles achieved fusion with the primary procedure [159]. Factors that improve arthrodesis results include arthroscopic or mini-incision technique, the use of more than two screws or an adjunct plate (or fibular strut), and a diagnosis of primary osteoarthritis [174]. With modern techniques, attention to detail, and management of concurrent medical conditions, fusion rates better than 90% should be expected in standard, uncomplicated ankle arthrodesis [174]. Evolving grade B evidence suggests that minimally invasive techniques may be equivalent to open procedures in selected patients for ankle arthrodesis [174].

Complications and Safety: A comprehensive systematic review demonstrates that ankle arthroscopy is a safe procedure with a low overall complication rate [14]. The incidence of cartilage injury during ankle arthroscopy is high, but severe damage was found in only 6.7% of cases [17]. Of the cartilage injuries found, 78.2% were superficial and 21.8% were deep [17]. Sixty-five percent of iatrogenic cartilage injuries occurred during the therapeutic portion of the procedure, while the remaining 35% occurred during portal creation [17]. The most common complication is neurologic injury, occurring in approximately 80% of complications, with approximately half involving the intermediate dorsal cutaneous branch of the superficial peroneal nerve [45]. Half of all complications in ankle arthroscopy are of neurovascular origin [82]. The structure at greatest risk during anterolateral portal placement is the intermediate dorsal cutaneous branch of the superficial peroneal nerve [45]. During posterolateral portal placement, the sural nerve and lesser saphenous vein are at greatest risk [45]. During posteromedial portal placement, the tibial nerve and posterior tibial artery and veins are at greatest risk [45]. Neurologic complications occurred in 10% of patients undergoing arthroscopic ligament repair or reconstruction for chronic ankle instability, while cutaneous complications and infection occurred in 4.2% requiring surgical revision [43]. The rate of cutaneous complications for arthroscopic ligament repair or reconstruction is at least half that of open surgery [43]. Two-stage arthroscopy is associated with significantly higher complication rates compared with single-stage arthroscopy for ligament repair or reconstruction [43]. Higher complications are noted with suture anchor fixation (29%) compared with suture fixation (9%) in arthroscopic ligament repair or reconstruction [43]. Entrapment of the peroneus tertius, extensor tendons, and the superficial peroneal nerve can occur when tying sutures for the anterior talofibular ligament during arthroscopic repair [43]. The use of intraoperative intra-articular corticosteroid injection at the time of ankle arthroscopy in Medicare patients is associated with significantly increased rates of postoperative infection compared with controls without intraoperative steroid injections [86].

Other Indications: There is sparse literature regarding the use of arthroscopy for treatment of septic arthritis of the ankle, with a grade C (poor evidence) recommendation for its use [43]. There are only small series (level IV studies) on the use of arthroscopy to treat arthrofibrosis of the ankle, most of which report promising results, but there is only a grade C recommendation (poor evidence) for its use [43]. Arthroscopic or open debridement of the arthritic ankle can be effective in the overall management plan, but it must be used judiciously and with realistic expectations of the outcome [136]. Debridement of more advanced arthritic ankles provides only short-term relief and is not recommended in most cases [136]. Increased motion following removal of impinging osteophytes in a joint with irregular arthritic surfaces may lead to different or increased pain postoperatively and should be discussed with the patient before surgery [136]. Aggressive removal of osteophytes also may lead to anterior extrusion of the talus postoperatively [136].

Complications

General Safety and Rates: The use of the dorsiflexion method for anterior ankle arthroscopy can prevent a significant number of complications [228]. A protocolized surgical technique aiming at lowering complications like sinus tract formation, infection, and neurovascular issues has been described [82]. Anatomical knowledge is critical to avoid neurovascular complications in ankle arthroscopy [82].

Neurovascular Complications: In 6.2% of cases, the anterior tibial artery and its branches were located near the anterolateral ankle portal, introducing a risk of vascular damage [224]. A technique for avoiding vein injury using a peripheral vein illumination device during anterior portal placement in ankle arthroscopy could lower the risk of complications [226]. The intermediate dorsal cutaneous branch of the superficial peroneal nerve crosses the inferior extensor retinaculum and is the primary structure at risk during arthroscopic repair [219]. Entrapment of the peroneus tertius, extensor tendons, and the superficial peroneal nerve can occur when tying sutures for the anterior talofibular ligament [43]. Neurologic complications occurred in 10% of patients undergoing arthroscopic ligament repair or reconstruction for chronic ankle instability [43].

Iatrogenic Cartilage Injury: Severe iatrogenic cartilage damage was found in only 6.7% of ankle arthroscopies [17]. Of the iatrogenic cartilage injuries found, 65% were sustained during the therapeutic portion of the arthroscopic procedure and the remaining 35% occurred during the portal creation portion [17]. Of the iatrogenic cartilage injuries found, 78.2% were superficial and 21.8% were deep [17].

Infection and Steroid Use: Big data suggest that because of a significant increased risk of postoperative infection, steroid injection is not recommended after ankle arthroscopy [240]. Cutaneous complications and infection occurred in 4.2% of patients undergoing arthroscopic ligament repair or reconstruction for chronic ankle instability, requiring surgical revision [43].

Ligament Repair and Reconstruction Complications: The complication rate of arthroscopic ligament repair or reconstruction is a concern, with rates between 11.5% and 18% reported in systematic reviews and one study of 119 patients [43]. In a systematic review of level IV studies on arthroscopic Broström techniques, there was a 17% complication rate [43]. The wide variations in the reported complication rates for arthroscopic lateral ankle repair range from 0% to 29% [219]. Complications associated with arthroscopic lateral ankle repair include nerve pain, knot irritation, delayed wound-healing, and deep vein thrombosis [219]. Two-stage arthroscopy was associated with significantly higher complication rates compared with single-stage arthroscopy [43]. Higher complications were noted with suture anchor fixation (29%) compared with suture fixation (9%) in arthroscopic ligament repair or reconstruction [43]. In a prospective study of arthroscopic all-inside anterior talofibular ligament repair, one patient in each group presented with neuralgia of the superficial peroneal nerve that improved over time without treatment [219]. Two patients in the inferior extensor retinaculum reinforcement group had knot irritation causing mild discomfort [219]. One patient in the no-inferior extensor retinaculum reinforcement group presented with an abscess requiring local incision and drainage [219].

Arthrodesis Complications: Arthroscopy significantly reduces the risk of postoperative complications while significantly increasing consolidation rates in arthroscopic tibiotalar and subtalar joint arthrodesis [241]. Both arthroscopic and mini-open ankle arthrodesis had good clinical outcomes, with high union rates and lower rates of complications [233].

Fracture-Related Complications: The study demonstrates a high rate of re-operation after ankle arthroscopy for fracture [223]. Leg anterior compartment syndrome following ankle arthroscopy after Maisonneuve fracture has been reported [18]. Pseudoaneurysm of the anterior tibial artery after ankle arthroscopy has been reported [18]. Pseudoaneurysm of the dorsalis pedis artery after ankle arthroscopy has been reported [18].

Recovery

Light activity (weeks): The evidence does not specify a distinct week range for light activities such as desk work or driving. However, accelerated rehabilitation protocols involving proactive weightbearing exercises from postoperative day 3 without ankle immobilization have been implemented following arthroscopic lateral ankle ligament repair [120].

Full activity (months): Following accelerated rehabilitation with proactive weightbearing exercises initiated on postoperative day 3 without ankle immobilization after arthroscopic lateral ankle ligament repair, 75% of patients achieved a complete return to sport within 8 weeks [120]. Most patients achieved excellent functional outcomes by 6 weeks, with high satisfaction and return to sport before 1 year following immediate weightbearing after augmented modified Broström reconstruction [221]. An accelerated rehabilitation program can be practiced for fully arthroscopic syndesmotic procedures, with fewer complications arising [166].

Complete recovery / outcome plateau (months): The literature identifies a clear deficiency in consistent, meaningful postoperative return to sport timeline data following lateral ankle ligament repair [165]. While specific plateau months are not defined in the provided evidence, anatomic lateral ankle ligament reconstruction with tendon autograft for isolated chronic lateral ankle instability provides tangible data on the expectable time frame of the individual return to sports and work trajectory [164].

Rehabilitation protocol: The success of lateral ankle instability surgery depends on proper phases of the rehabilitation period [114]. Protocols may include accelerated rehabilitation with proactive weightbearing exercises from postoperative day 3 without ankle immobilization [120], or immediate weightbearing after augmented modified Broström reconstruction [221]. An accelerated rehabilitation program is applicable for fully arthroscopic syndesmotic procedures [166].

Functional milestones: Short-term AOFAS functional outcome scores were significantly improved with arthroscopic lateral ankle repair compared to open repair [229]. The ALR-RSI is a valid, reproducible scale with which to identify patients who are ready to resume the same sport after ankle ligament reconstruction [222]. Only subjects with chronic ankle instability had reductions in self-reported function compared to healthy individuals and ankle sprain copers [193].

Other Considerations: Ankle arthroscopy is associated with decreased morbidity and faster recovery times compared with open arthrotomy [12]. Arthroscopic ankle lateral ligament repair is a reliable procedure for patients requiring return to high demanding sports after severe acute ankle sprains [163]. All patients were able to return to their preoperative occupational and athletic activities following reconstruction of the lateral ligaments of the ankle using the plantaris tendon [184]. Ankle stability resumed with a high clinical success rate following a new arthroscopic Broström procedure for chronic lateral ankle instability [48]. The clinical and radiologic outcomes of patients with chronic ankle instability improved after all-inside arthroscopic anterior talofibular ligament repair [50]. Arthroscopic repair of lateral ankle ligament, when feasible, produced similarly favorable outcomes compared with open lateral ankle repair at 2 years [231]. Residual ankle instability was associated with worse postoperative outcomes in patients undergoing autologous matrix-induced chondrogenesis with lateral ligament stabilization for osteochondral lesions of the talus [232].

Key Evidence

• [L5] When used for the appropriate indications, ankle arthroscopy appears to give good results. [1] (10.5435/00124635-199601000-00004)
• [L4] There exists adequate evidence-based literature to support the surgical technique of ankle arthroscopy for most current generally accepted indications; however, further studies in this area are needed. [2] (10.1016/j.arthro.2009.05.001)
• [L4] Ankle arthroscopy was performed more frequently in female patients and most commonly in patients younger than 50 years, with a significant increase in its use for lateral ankle instability management. [3] (10.1016/j.arthro.2015.01.020)
• [L5] Operative procedures that only focus on part of the pathology should be approached with caution until assessment of a patient with ankle instability defines all deficiencies. [4] (10.2106/jbjs.21.00726)
• [L3] This first prospective study to evaluate posterior ankle arthroscopy in an exclusively young population demonstrates promising outcomes, supporting its role in the management of posterior ankle pathology. [5] (10.1177/2325967126s00420)
• [L5] Posterior ankle arthroscopy is a powerful diagnostic and therapeutic modality for orthopaedic foot and ankle surgeons. [7] (10.1016/j.eats.2024.103322)
• [L5] Posterior ankle arthroscopy is a powerful diagnostic and therapeutic modality for orthopaedic foot and ankle surgeons. [8] (10.1016/j.eats.2024.103323)
• [L5] The number of indications for anterior ankle arthroscopy is rising, and open surgery is increasingly replaced by arthroscopic surgery. [9] (10.1136/jisakos-2015-000009)
• [L5] This article outlines the current state of the art for posterior ankle arthroscopy, covering diagnostics, surgical techniques, complications, geographical differences, and future developments. [10] (10.1136/jisakos-2016-000082)
• [L2] Although only fair-quality evidence exists in support of open operative treatment of chronic ankle instability, this systematic review helps reassure clinicians of their current practices. [11] (10.1136/jisakos-2018-000265)
• [L5] Ankle arthroscopy is a relatively new and dynamic tool with decreased morbidity and faster recovery times compared with open arthrotomy. [12] (10.5435/00124635-199601000-00003)
• [L4] When performing ankle arthroscopy, it is important to remember the potential complications and try to avoid them. [13] (10.1530/eor-22-0144)
• [L1] This comprehensive systematic review demonstrates that ankle arthroscopy is a safe procedure with a low overall complication rate. [14] (10.1302/0301-620x.105b3.bjj-2022-0796.r1)
• [L5] With sound knowledge regarding the indications, merits, and potential risks of new techniques, they will be powerful tools in foot and ankle surgery. [15] (10.1016/j.arthro.2007.03.003)
• [L4] [17] (10.1007/s00167-014-3237-5)
• [L4] This survey reflected the heterogeneity of surgical practices in ankle instability and provided indications for areas of research in clinical situations with the least consensus. [19] (10.1177/2325967120s00009)
• [L5] It may hold the potential to make ankle arthroscopy less invasive and more accessible. [21] (10.1007/s00167-020-05889-7)
• [L4] The final diagnosis of chronic instability of the anterior syndesmosis can be made during arthroscopy of the ankle. [22] (10.1186/1471-2474-12-212)
• [L4] Posterior ankle arthroscopy was effective in patients with residual symptoms after syndesmosis injury. [23] (10.1177/23259671231200934)
• [L2] The endoscopic approach also allows assessment of the ankle joint and treatment of associated intra-articular lesions. [25] (10.1007/s00167-019-05793-9)
• [L4] [26] (10.1177/03635465020300031601)
• [L5] Ankle arthroscopy has become a very handy tool for helping patients to alleviate ankle pain as long as the indication is fulfilled. [27] (10.1177/2325967121s00849)
• [L4] On the basis of these findings, arthroscopic treatment of anterolateral ankle soft-tissue impingement is a very safe procedure when indicated. [28] (10.1016/j.arthro.2013.10.014)
• [L4] Ankle arthroscopy is a useful adjuvant tool to understand the severity and complexity of acute ankle fracture. [30] (10.1016/j.arthro.2016.08.016)
• [L3] Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise but require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes. [31] (10.1016/j.otsr.2018.09.005)
• [Case_report] Anterior ankle arthroscopy is of great value in the diagnostic work-up and treatment, and was superior to MRI in detecting this type of pathology. [33] (10.1007/s00167-012-2077-4)
• [L3] Combining ankle arthroscopy with a modified Brostrom procedure provided significantly improved ankle hindfoot scores at an average of 35 months follow up. [34] (10.1016/j.arthro.2009.04.063)
• [L4] The review suggests that posterior ankle arthroscopy is a safe and effective surgical procedure in the treatment of posterior ankle impingement. [37] (10.1016/j.arthro.2007.08.025)
• [L4] This arthroscopic classification of chronic ATFL lesions confirms the diagnostic role for arthroscopy in assessing the ligaments in patients with CAI and is helpful for determining the best surgical technique for stabilising the ankle. [39] (10.1016/j.otsr.2018.09.004)
• [L2] Arthroscopy plays a crucial role in the definitive assessment of ligament lesions in patients with chronic ankle instability, supplying far more accurate information than any of the current imaging studies. [40] (10.1016/j.otsr.2018.09.008)
• [L5] Although it reflects a normal anatomical finding, it could lead to anterolateral impingement in cases with coexistent ankle instability. [41] (10.1177/0095399703258697)
• [L4] Anatomical reconstruction of the ATFL is a recommendable choice for treating functional ankle instability in cases with morphologic ligamentous abnormality. [42] (10.1177/0363546508315537)
• [L4] Ankle stability resumed with a high clinical success rate. [48] (10.1186/s13018-023-03789-3)
• [L3] The clinical and radiologic outcomes of patients with chronic ankle instability improved after all-inside arthroscopic ATFL repair. [50] (10.1177/03635465211008097)
• [L4] The modified Broström procedure combined with ankle arthroscopy produced satisfactory surgical outcomes in patients with chronic ankle instability accompanied by intra-articular symptoms. [55] (10.1016/j.arthro.2010.02.002)
• [Paper] Diagnostic arthroscopy is a useful adjunct for diagnosing consolidation in cases with equivocal imaging findings. [57] (10.1016/j.eats.2019.08.001)
• [L5] Ankle arthroscopy is essential for diagnosis and treatment, allowing for the evaluation of anatomic reduction and residual diastasis. [58] (10.1177/2325967121s00851)
• [L2] [61] (10.1007/s00167-012-2063-x)
• [L2] A driving abstinence of two weeks is necessary after right-sided ankle arthroscopy. [62] (10.1016/j.injury.2015.11.011)
• [L4] Surgically, both arthroscopic and open repair techniques appear biomechanically equivalent in their ability to restore ankle stability, although sufficient evidence is still lacking for any particular procedure to be considered a superior construct. [67] (10.5435/jaaos-d-20-00145)
• [L2] [68] (10.1007/s00167-014-3399-1)
• [L4] Acute instabilities generally undergo conservative treatment while chronic instabilities are better addressed with surgery, and ankle arthroscopy is becoming a mandatory tool for both diagnosis and treatment. [69] (10.1302/2058-5241.6.210017)
• [L4] Recognition of the ankle fracture component is important as it may alter the surgical plan and postoperative management. [70] (10.1007/s00402-014-2095-4)
• [L4] [71] (10.1177/03635465221084365)
• [Paper] Posterior ankle endoscopy in the supine position is a safe and effective approach for treatment of posterior ankle impingement, particularly when concomitant anterior ankle pathology requires anterior arthroscopy, allowing treatment of both pathologies without changing patient position. [72] (10.1016/j.eats.2016.07.006)
• [Letter] [82] (10.1007/s00167-012-2337-3)
• [L4] [85] (10.1016/j.arthro.2017.12.003)
• [L4] The use of intraoperative intra-articular corticosteroid injection at the time of ankle arthroscopy in Medicare patients is associated with significantly increased rates of postoperative infection compared with controls without intraoperative steroid injections. [86] (10.1016/j.arthro.2015.07.029)
• [L3] This supports the interpretation that the dynamic congruency of the joint, which is influenced by ligamentous integrity remains the main anatomical component in mechanical ankle instability. [90] (10.1186/s12891-025-09458-2)
• [L4] The operative ankle exhibited greater syndesmosis length and altered kinematics compared to the healthy side during all tested activities. [92] (10.2106/jbjs.20.01787)
• [L5] The no-distraction and dorsiflexion technique is the key for ankle arthroscopy evolution as it allows for more advanced third-generation procedures and reduces morbidity compared to routine-distraction. [100] (10.1016/j.arthro.2018.02.011)
• [L4] Medial and lateral antero-superior ancillary portals have strong value in addressing repair procedures to ankle joint compartments blind to traditional arthroscopic access. [102] (10.1016/j.arthro.2016.03.079)
• [L4] All-arthroscopic technique for anatomic reconstruction for chronic lateral ankle instability leads to good clinical results. [105] (10.1016/j.arthro.2017.08.159)
• [L4] Arthroscopic surgery and tendoscopy are emerging procedures for management of several disorders of the posterior ankle, subtalar joint, and first metatarsophalangeal joint that can be both diagnostic and therapeutic while preserving the soft-tissue envelope to a much greater extent than open surgery. [106] (10.5435/jaaos-22-01-10)
• [L4] Plantar flexion of the ankle produces changes in radiographic measurements of the medial clear space. [108] (10.2106/jbjs.i.00084)
• [L5] Ankle arthroscopy has evolved from a diagnostic to a therapeutic tool, with anterior procedures effectively treating impingement and osteochondral defects using dorsiflexion rather than routine distraction. [113] (10.5435/00124635-200811000-00004)
• [L5] The success of lateral ankle instability surgery also depends on proper phases of the rehabilitation period. [114] (10.1177/2325967124s00376)
• [L5] The greatest increases in laxity after sectioning the ligament occurred in ankle positions and loads corresponding to common modes of injury. [117] (10.2106/00004623-198365010-00011)
• [L4] When accelerated rehabilitation with proactive weightbearing exercises was implemented from postoperative day 3 without ankle immobilization after ALLR, there were significant improvements in objective assessments of ankle stability and clinical scores, and as many as 75% of the patients were able to make a complete return to sport within 8 weeks. [120] (10.1177/23259671221121676)
• [L3] [124] (10.1002/ksa.12079)
• [L3] [127] (10.1016/j.arthro.2020.01.053)
• [L5] The number of mechanoreceptors was negatively correlated with ankle sensorimotor dysfunction. [128] (10.1177/03635465231217490)
• [L2] Most studies found distinct characteristics of the incisura fibularis morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement. [129] (10.1016/j.jisako.2024.100361)
• [L3] Abnormal internal rotation of the talus in patients with mechanical ankle instability was decreased after ankle lateral stabilization surgery. [132] (10.1177/23259671211023447)
• [L4] The Diagnostic Ankle Arthroscopy Skills Scoring System was a valid measure to objectively assess trainees' ankle arthroscopy clinical knowledge and operative skills in a bioskills laboratory. [143] (10.1177/1071100719891418)
• [L5] Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus. [145] (10.2106/00004623-199607000-00006)
• [L5] In this biomechanical model, isolated posterior malleolus osteotomy and isolated anterior inferior tibiobular ligament and interosseous ligament rupture only partially increased fibular motion in dorsiflexion and plantar flexion, whereas the combination of posterior malleolus osteotomy and anterior inferior tibiobular ligament and interosseous ligament rupture resulted in an unstable syndesmosis in all planes. [149] (10.2106/jbjs.23.01088)
• [L3] The ATFL–PTFL angle decreases after ankle lateral stabilization surgery. [152] (10.1007/s00167-020-06174-3)
• [L3] Simultaneous arthroscopy, independent of pre-operative MRI findings, appears reasonable in highly active patients. [156] (10.1007/s00167-020-06141-y)
• [L5] [157] (10.1002/ksa.12538)
• [L4] Grading of the three major ligamentous complexes and of the individual ankle ligaments according the Schneck grading system resulted in limited diagnostic reliability. [160] (10.1136/jisakos-2020-000503)
• [L5] This international consensus derived from leaders in the field will assist clinicians with the appropriate terminology for osteochondral lesions of the ankle. [162] (10.1016/j.jisako.2021.12.001)
• [L3] Ankle arthroscopy followed by open anatomic ligament repair is a reliable procedure for patients requiring return to high demanding sports after severe acute ankle sprains. [163] (10.1186/s12891-022-05260-6)
• [L4] These results may be helpful in preoperatively managing patients' expectations regarding sports- and work-related outcomes and provide tangible data on the expectable time frame of the individual return to sports and work trajectory. [164] (10.1007/s00167-022-06937-0)
• [L4] The review identifies a clear deficiency in the literature pertaining to consistent, meaningful postoperative return to sport timeline following lateral ankle ligament repair. [165] (10.1136/jisakos-2016-000064)
• [L4] An accelerated rehabilitation program can be practiced and fewer complications arise, since it is a fully arthroscopic procedure. [166] (10.1016/j.arthro.2008.04.062)
• [L5] Surgeons may consider using novel techniques such as suture anchors, synthetic augmentation, and all-arthroscopic stabilization in the management of lateral ankle instability. [168] (10.5435/jaaos-d-20-00176)
• [L5] Arthroscopic treatment of ankle instability is emerging as the potential gold standard technique, offering the advantage of addressing both instability and associated intra-articular pathology in a single procedure with excellent results. [175] (10.1016/j.arthro.2020.10.043)
• [L5] [178] (10.5435/00124635-199603000-00001)
• [L3] About 20% of athletes referred for MRI after suffering an acute ankle sprain had evidence of a syndesmotic injury regardless of lateral ligament involvement, while more than half had evidence of any lateral ligament injury without syndesmotic involvement. [181] (10.1177/0363546514529643)
• [L4] All patients were able to return to their preoperative occupational and athletic activities. [184] (10.2106/00004623-198567060-00016)
• [L4] [187] (10.1007/s00167-018-5117-x)
• [L5] [188] (10.1530/eor-22-0024)
• [L4] [189] (10.1016/j.eats.2022.07.018)
• [L3] Preoperative MRI is a reliable and valid decision making tool for the choice of surgical stabilization technique in patients with chronic lateral ankle instability. [191] (10.1016/j.arthro.2017.04.066)
• [L5] Recent advancements in IONA technology have made it possible to perform arthroscopic procedures under local anesthesia in the office setting, revolutionizing the treatment of foot and ankle pathologies. [192] (10.1016/j.arthro.2023.01.005)
• [L3] Only subjects with chronic ankle instability had reductions in self-reported function. [193] (10.2519/jospt.2012.3923)
• [L2] Traditional radiographic measurements should not be relied on solely for determining if the syndesmosis is intact and the ankle mortise is stable. [195] (10.1097/01.blo.0000161090.86162.19)
• [L3] [196] (10.1186/s13018-022-02968-y)
• [L1] [198] (10.1016/j.arthro.2022.11.035)
• [L2] In cases of symptomatic posterior ankle impingement, we advise that a PIM view be used instead of or in addition to the standard lateral view for detection of posterior talar pathologic conditions. [207] (10.1016/j.arthro.2014.05.006)
• [L4] [208] (10.1002/ksa.12328)
• [L3] MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time. [209] (10.1007/s00167-019-05581-5)
• [L4] The presence of an osteochondral lesion had a negative effect on the overall result when compared to that of patients who underwent lateral ankle stabilization as an isolated procedure. [213] (10.1177/0363546509351556)
• [L1] [219] (10.2106/jbjs.20.01696)
• [L4] Most patients achieved excellent functional outcomes by 6 weeks, with minimal complications, high satisfaction, and return to sport before 1 year. [221] (10.1177/23259671251389196)
• [L4] The ALR-RSI is a valid, reproducible scale with which to identify patients who are ready to resume the same sport after ankle ligament reconstruction. [222] (10.1177/2325967121s00010)
• [L4] The study demonstrates a high rate of re-operation after ankle arthroscopy for fracture. [223] (10.1007/s00167-014-3140-0)
• [L4] In 6.2% of cases, the anterior tibial artery and its branches were located near the anterolateral ankle portal, introducing a risk of vascular damage. [224] (10.1177/0363546511416317)
• [Paper] The technique for avoiding vein injury using a peripheral vein illumination device during anterior portal placement in ankle arthroscopy could lower the risk of complications. [226] (10.1016/j.eats.2017.08.060)
• [L3] They also conclude that the use of the dorsiflexion method for anterior ankle arthroscopy can prevent a significant number of complications. [228] (10.1007/s00167-012-2092-5)
• [L1] Short-term AOFAS functional outcome scores were significantly improved with arthroscopic lateral ankle repair compared to open repair. [229] (10.1007/s00167-018-5100-6)
• [L3] When compared with open lateral ankle repair, arthroscopic repair of lateral ankle ligament when feasible produced similarly favorable outcomes. [231] (10.1177/0363546517698675)
• [L3] However, residual ankle instability was associated with worse postoperative outcomes, highlighting the need for adequate stabilization of ankle instability in patients with OLT. [232] (10.1177/23259671211007439)
• [L3] Both arthroscopic and mini-open ankle arthrodesis had good clinical outcomes, with high union rates and lower rates of complications. [233] (10.1016/j.arthro.2017.08.160)
• [L5] Big data suggest that because of a significant increased risk of postoperative infection, steroid injection is not recommended after ankle arthroscopy. [240] (10.1016/j.arthro.2015.12.015)
• [L4] Arthroscopy significantly reduces the risk of postoperative complications while significantly increasing consolidation rates (nonunion < 10%). [241] (10.1016/j.otsr.2015.06.033)

See Also

• Ankle impingement
• Chronic ankle instability
• Syndesmotic injury
• Ankle fracture
• Ankle fracture fixation
• Lateral ligament reconstruction
• Ankle arthrodesis

References

[1] Ankle Arthroscopy: II. Indications and Results. Journal of the American Academy of Orthopaedic Surgeons. 1996. DOI: 10.5435/00124635-199601000-00004

[2] Evidence‐Based Indications for Ankle Arthroscopy. Arthroscopy. 2009. DOI: 10.1016/j.arthro.2009.05.001

[3] Trends in Ankle Arthroscopy and Its Use in the Management of Pathologic Conditions of the Lateral Ankle in the United States: A National Database Study. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.01.020

[4] Ankle Stability. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.21.00726

[5] Poster 116. Pediatric Posterior Ankle Arthroscopy- Indications and Outcomes: A Prospective Study. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00420

[7] Basics of Ankle Arthroscopy Part 3: Patient Positioning and Preparation for Posterior Ankle Arthroscopy. Arthroscopy Techniques. 2024. DOI: 10.1016/j.eats.2024.103322

[8] Basics of Ankle Arthroscopy Part 4: Surface Anatomy, Portal Placement, and Diagnostic Evaluation for Posterior Ankle Arthroscopy. Arthroscopy Techniques. 2024. DOI: 10.1016/j.eats.2024.103323

[9] Anterior ankle arthroscopy: state of the art. Journal of ISAKOS. 2016. DOI: 10.1136/jisakos-2015-000009

[10] Posterior ankle arthroscopy: current state of the art. Journal of ISAKOS. 2017. DOI: 10.1136/jisakos-2016-000082

[11] Fair evidence consistently supports open surgical treatment for chronic ankle instability: a systematic review. Journal of ISAKOS. 2019. DOI: 10.1136/jisakos-2018-000265

[12] Ankle Arthroscopy: I. Technique and Complications. Journal of the American Academy of Orthopaedic Surgeons. 1996. DOI: 10.5435/00124635-199601000-00003

[13] Complications of ankle arthroscopy: frequency, prevention, and treatment. EFORT Open Reviews. 2024. DOI: 10.1530/eor-22-0144

[14] Complications following ankle arthroscopy. The Bone & Joint Journal. 2023. DOI: 10.1302/0301-620x.105b3.bjj-2022-0796.r1

[15] Arthroscopy and Endoscopy of the Foot and Ankle: Indications for New Techniques. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.03.003

[17] Iatrogenic articular cartilage injuries during ankle arthroscopy. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3237-5

[18] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC EXAMINATION AND DEBRIDEMENT OF THE ANKLE JOINT > COMPLICATIONS.

[19] Results of a survey of practices in chronic ankle instability in France. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120s00009

[21] Two-millimetre diameter operative arthroscopy of the ankle is safe and effective. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-05889-7

[22] Chronic instability of the anterior tibiofibular syndesmosis of the ankle. Arthroscopic findings and results of anatomical reconstruction. BMC Musculoskeletal Disorders. 2011. DOI: 10.1186/1471-2474-12-212

[23] Treatment of Intra-Articular Lesions After Posterior Inferior Tibiofibular Ligament Injury: A Case Series of Elite Rugby Players. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/23259671231200934

[25] Endoscopic anatomic ligament reconstruction is a reliable option to treat chronic lateral ankle instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05793-9

[26] Arthroscopic Findings in Patients with Chronic Ankle Instability. The American Journal of Sports Medicine. 2002. DOI: 10.1177/03635465020300031601

[27] Indications and Settings for Ankle Arthroscopy. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967121s00849

[28] Safety of Ankle Arthroscopy for the Treatment of Anterolateral Soft‐Tissue Impingement. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2013.10.014

[30] Role of Ankle Arthroscopy in Management of Acute Ankle Fracture. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.08.016

[31] Arthroscopic treatment of chronic ankle instability: Prospective study of outcomes in 286 patients. Orthopaedics & Traumatology: Surgery & Research. 2018. DOI: 10.1016/j.otsr.2018.09.005

[33] “Web impingement” of the ankle: a case report. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2077-4

[34] One‐Step Anterior and Posterior Ankle Arthroscopy by Double Postero‐Medial Portals: 6 Years Follow‐Up Prospective Study (SS‐64). Arthroscopy. 2009. DOI: 10.1016/j.arthro.2009.04.063

[37] Outcome of Posterior Ankle Arthroscopy for Hindfoot Impingement. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.08.025

[39] Arthroscopic classification of chronic anterior talo-fibular ligament lesions in chronic ankle instability. Orthopaedics & Traumatology: Surgery & Research. 2018. DOI: 10.1016/j.otsr.2018.09.004

[40] Agreement between arthroscopic and imaging study findings in chronic anterior talo-fibular ligament injuries. Orthopaedics & Traumatology: Surgery & Research. 2018. DOI: 10.1016/j.otsr.2018.09.008

[41] The Accessory Anteroinferior Tibiofibular Ligament as a Cause of Talar Impingement. The American Journal of Sports Medicine. 2004. DOI: 10.1177/0095399703258697

[42] Arthroscopic and Magnetic Resonance Image Appearance and Reconstruction of the Anterior Talofibular Ligament in Cases of Apparent Functional Ankle Instability. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546508315537

[43] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC EXAMINATION AND DEBRIDEMENT OF THE ANKLE JOINT > ANKLE INSTABILITY.

[45] Aaos Comprehensive Orthopaedic Review 3. Arthroscopy of the Ankle > VII. Acute Traumatic Ankle Injuries.

[48] Mid-term follow-up evaluation of a new arthroscopic Broström procedure for chronic lateral ankle instability. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03789-3

[50] Additional Inferior Extensor Retinaculum Augmentation After All-Inside Arthroscopic Anterior Talofibular Ligament Repair for Chronic Ankle Instability Is Not Necessary. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211008097

[52] Apley And Solomon S Concise System Of Orthopaedics And Trauma. INJURIES OF THE ANKLE.

[55] Combination of Modified Broström Procedure With Ankle Arthroscopy for Chronic Ankle Instability Accompanied by Intra‐articular Symptoms. Arthroscopy. 2010. DOI: 10.1016/j.arthro.2010.02.002

[57] Ankle Arthroscopy as an Adjunctive Method for Diagnosis of Nonunion After Tibiotalar Arthrodesis. Arthroscopy Techniques. 2019. DOI: 10.1016/j.eats.2019.08.001

[58] Syndesmosis Instability. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967121s00851

[61] Complications in ankle arthroscopy. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2063-x

[62] Driving ability after right-sided ankle arthroscopy—A prospective Study. Injury. 2016. DOI: 10.1016/j.injury.2015.11.011

[67] Diagnosis and Treatment of Chronic Lateral Ankle Instability: Review of Our Biomechanical Evidence. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-20-00145

[68] Magnetic resonance imaging characterization of individual ankle syndesmosis structures in asymptomatic and surgically treated cohorts. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3399-1

[69] Ankle and syndesmosis instability: consensus and controversies. EFORT Open Reviews. 2021. DOI: 10.1302/2058-5241.6.210017

[70] Ankle injuries in distal tibial spiral shaft fractures: results from an institutional change in imaging protocol. Archives of Orthopaedic and Trauma Surgery. 2014. DOI: 10.1007/s00402-014-2095-4

[71] One in Three Patients With Chronic Lateral Ankle Instability Has a Cartilage Lesion. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221084365

[72] Decompression of Posterior Ankle Impingement With Concomitant Anterior Ankle Pathology by Posterior Ankle Arthroscopy in the Supine Position. Arthroscopy Techniques. 2016. DOI: 10.1016/j.eats.2016.07.006

[73] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC EXAMINATION AND DEBRIDEMENT OF THE ANKLE JOINT > ANKLE FRACTURES.

[82] Response to: comment on “complications in ankle arthroscopy”: Anatomy, an important factor to avoid complications related to ankle arthroscopy. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-012-2337-3

[85] Ankle Arthroscopy for Diagnosis of Full‐thickness Talar Cartilage Lesions in the Setting of Acute Ankle Fractures. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2017.12.003

[86] Risk of Infection After Intra‐articular Steroid Injection at the Time of Ankle Arthroscopy in a Medicare Population. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.07.029

[87] Miller S Review Of Orthopaedics. BIOMECHANICS OF THE FOOT AND ANKLE.

[90] Three-dimensional talar shape seems not a factor in chronic mechanical ankle instability. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-025-09458-2

[91] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > ANKLE BLOCK.

[92] Syndesmosis Repair Affects in Vivo Distal Interosseous Tibiofibular Ligament Elongation Under Static Loads and During Dynamic Activities. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01787

[93] Orthopaedic Knowledge Update Sports Medicine 6. Ankle and Foot Injuries and Other Disorders > Ankle Sprains > Medial Ankle Injury.

[95] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Foot and Ankle Anatomy and Biomechanics > Annotated References.

[96] Rockwood And Green S Fractures In Adults. 59: Patellar Fractures and Dislocations and Extensor Mechanism Injuries > Imaging and Other Diagnostic Studies for Ankle Fractures > Radiography.

[100] “Ankle Arthroscopy: No‐Distraction and Dorsiflexion Technique Is the Key for Ankle Arthroscopy Evolution”. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.02.011

[102] Arthroscopic Antero‐superior Ancillary Portals for Addressing Surgical Repair perpendicularly on Talar Dome: Sixteen Years’ Experience. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.03.079

[104] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC EXAMINATION AND DEBRIDEMENT OF THE ANKLE JOINT > ANKLE IMPINGEMENT SYNDROMES.

[105] Paper #195: Clinical Results Of Arthroscopic Anatomical Reconstruction Of The Lateral Ankle Ligaments. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.08.159

[106] Extended Indications for Foot and Ankle Arthroscopy. Journal of the American Academy of Orthopaedic Surgeons. 2014. DOI: 10.5435/jaaos-22-01-10

[108] Plantar Flexion Influences Radiographic Measurements of the Ankle Mortise. The Journal of Bone and Joint Surgery-American Volume. 2010. DOI: 10.2106/jbjs.i.00084

[113] Advancements in Ankle Arthroscopy. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200811000-00004

[114] Arthroscopic ankle lateral ligament instabilities repair. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00376

[117] The contribution of the anterior talofibular ligament to ankle laxity.. The Journal of Bone & Joint Surgery. 1983. DOI: 10.2106/00004623-198365010-00011

[120] Effect of Accelerated Rehabilitation on Early Return to Sport After Arthroscopic Ankle Lateral Ligament Repair. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221121676

[124] Acute clinical evaluation for the diagnosis of lateral ankle ligament injuries is useful: A comparison between the acute and delayed settings. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12079

[127] Arthroscopy‐Assisted Reduction in the Management of Isolated Medial Malleolar Fracture. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.01.053

[128] Chronic Ankle Joint Instability Induces Ankle Sensorimotor Dysfunction: A Controlled Laboratory Study. The American Journal of Sports Medicine. 2024. DOI: 10.1177/03635465231217490

[129] Ligamentous ankle injuries in relation to the morphology of the incisura fibularis: A systematic review. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2024.100361

[132] Decreasing the Abnormal Internally Rotated Talus After Lateral Ankle Stabilization Surgery. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211023447

[136] Campbell S Operative Orthopaedics 4 Volume Set. Reported Outcomes of Ankle Arthroplasty Compared With Ankle Arthrodesis > OPERATIVE TREATMENT.

[143] Assessment of Basic Ankle Arthroscopy Skills in Orthopedic Trainees. Foot & Ankle International. 2019. DOI: 10.1177/1071100719891418

[145] Motion of the Ankle in a Simulated Supination-External Rotation Fracture Model. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199607000-00006

[149] Assessing the Need for Additional Syndesmotic Stabilization in Open Reduction of the Posterior Malleolus. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.23.01088

[152] The anterior talofibular ligament–posterior talofibular ligament angle decreased after ankle lateral stabilization surgery. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06174-3

[154] Aaos Comprehensive Orthopaedic Review 3. Arthroscopy of the Ankle > III. Anterolateral Soft-­Tissue Impingement.

[156] Acute, isolated and unstable syndesmotic injuries are frequently associated with intra‐articular pathologies. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06141-y

[157] The ankle sprain and the domino effect. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12538

[159] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Degenerative Conditions and Osteonecrosis of the Foot and Ankle > Ankle > Arthrodesis.

[160] Limited intrarater and interrater reliability of acute ligamentous ankle injuries on 3 T MRI. Journal of ISAKOS. 2021. DOI: 10.1136/jisakos-2020-000503

[162] Terminology for osteochondral lesions of the ankle: proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle. Journal of ISAKOS. 2022. DOI: 10.1016/j.jisako.2021.12.001

[163] Distal insertion rupture of lateral ankle ligament as a predictor of weakened and delayed sports recovery after acute ligament repair: mid-term outcomes of 117 cases. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05260-6

[164] High return to sports and return to work rates after anatomic lateral ankle ligament reconstruction with tendon autograft for isolated chronic lateral ankle instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-06937-0

[165] Return to sport following lateral ankle ligament repair is under-reported: a systematic review. Journal of ISAKOS. 2017. DOI: 10.1136/jisakos-2016-000064

[166] Ankle Syndesmotic Ligaments Injury: Total Arthroscopic Procedure Assisted With a New Anterosuperior Portal. Three‐Year First Results (SS‐62). Arthroscopy. 2008. DOI: 10.1016/j.arthro.2008.04.062

[168] Evolution in Surgical Management of Ankle Instability in Athletes. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-00176

[174] Campbell S Operative Orthopaedics 4 Volume Set. Reported Outcomes of Ankle Arthroplasty Compared With Ankle Arthrodesis > COMPLICATIONS.

[175] Editorial Commentary: Arthroscopic Treatment of Ankle Instability Is the Emerging Gold Standard. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2020.10.043

[178] Osteochondral Lesions of the Talar Dome. Journal of the American Academy of Orthopaedic Surgeons. 1996. DOI: 10.5435/00124635-199603000-00001

[181] Ligamentous Injuries and the Risk of Associated Tissue Damage in Acute Ankle Sprains in Athletes. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514529643

[184] Reconstruction of the lateral ligaments of the ankle using the plantaris tendon.. The Journal of Bone & Joint Surgery. 1985. DOI: 10.2106/00004623-198567060-00016

[187] Arthroscopic all-inside anterior talo-fibular ligament repair with suture augmentation gives excellent results in case of poor ligament tissue remnant quality. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5117-x

[188] Osteochondral lesion of the talus: still a problem?. EFORT Open Reviews. 2022. DOI: 10.1530/eor-22-0024

[189] Low‐Flow Ankle Arthroscopy for Gunshot Wounds With Retained Intra‐Articular Ballistic. Arthroscopy Techniques. 2022. DOI: 10.1016/j.eats.2022.07.018

[191] Reliability and Validity of Preoperative MRI for Surgical Decision Making in the Chronic Lateral Ankle Instability. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.04.066

[192] In‐Office Needle Arthroscopy for the Foot and Ankle. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.01.005

[193] Differences in Lateral Ankle Laxity Measured via Stress Ultrasonography in Individuals With Chronic Ankle Instability, Ankle Sprain Copers, and Healthy Individuals. Journal of Orthopaedic & Sports Physical Therapy. 2012. DOI: 10.2519/jospt.2012.3923

[195] Radiographic Measurements Do Not Predict Syndesmotic Injury in Ankle Fractures. Clinical Orthopaedics and Related Research. 2005. DOI: 10.1097/01.blo.0000161090.86162.19

[196] Limited medial osteochondral lesions of the talus associated with chronic ankle instability do not impact the results of endoscopic modified Broström ligament repair. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-02968-y

[198] Both Open and Arthroscopic All‐Inside Anatomic Reconstruction With Autologous Gracilis Tendon Restore Ankle Stability in Patients With Chronic Lateral Ankle Instability. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.11.035

[207] The Posterior Impingement View: An Alternative Conventional Projection to Detect Bony Posterior Ankle Impingement. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.05.006

[208] Arthroscopic anterior deltoid plication with bone anchor is an effective procedure to control residual talar anterior translation after lateral ligament repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12328

[209] MRI for high ankle sprains with an unstable syndesmosis: posterior malleolus bone oedema is common and time to scan matters. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05581-5

[213] Treatment of the Unstable Ankle with an Osteochondral Lesion. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546509351556

[219] Arthroscopic All-Inside Anterior Talofibular Ligament Repair with and without Inferior Extensor Retinacular Reinforcement. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01696

[221] Immediate Weightbearing After Augmented Modified Broström Reconstruction: A Retrospective Review of an Accelerated Rehabilitation Protocol. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251389196

[222] Ankle Ligament Reconstruction - Return to Sport after Injury (ALR-RSI): a valid scale to quantify psychological readiness to return to sports after ankle ligament reconstruction. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00010

[223] Ankle arthroscopy to manage sequelae after ankle fractures. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3140-0

[224] Is the Anterior Tibial Artery Safe During Ankle Arthroscopy?. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511416317

[226] A Technique for the Reduction of Complications Associated With Anterior Portal Placement During Ankle Arthroscopy Using a Peripheral Vein Illumination Device. Arthroscopy Techniques. 2018. DOI: 10.1016/j.eats.2017.08.060

[228] Low risk of complications during ankle arthroscopy. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2092-5

[229] Arthroscopic versus open repair of lateral ankle ligament for chronic lateral ankle instability: a meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5100-6

[231] Activity Level and Function 2 Years After Anterior Talofibular Ligament Repair: A Comparison Between Arthroscopic Repair and Open Repair Procedures. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517698675

[232] Autologous Matrix-Induced Chondrogenesis With Lateral Ligament Stabilization for Osteochondral Lesions of the Talus in Patients With Ankle Instability. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211007439

[233] Paper #196: Mini‐Open and Arthroscopic Ankle Arthrodesis. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.08.160

[240] Editorial Commentary: Big Data Suggest That Because of a Significant Increased Risk of Postoperative Infection, Steroid Injection Is Not Recommended After Ankle Arthroscopy. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2015.12.015

[241] Arthroscopic tibiotalar and subtalar joint arthrodesis. Orthopaedics & Traumatology: Surgery & Research. 2016. DOI: 10.1016/j.otsr.2015.06.033