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Lateral ligament reconstruction

132 citationsUpdated Sep 2026

Overview

Reconstruction of the unstable lateral ligament complex is a relatively stable treatment for chronic ankle instability, yielding a high rate of success [1, 4]. The primary surgical options are anatomic ligament repair with reinforcement and anatomic ligament reconstruction [2]. These procedures are indicated for patients with severe chronic lateral ankle instability, where allograft reconstruction serves as a valid treatment option that leads to satisfying outcomes and reduced joint morbidity [3]. Anatomic stabilization techniques provide superior functional results compared to non-anatomic methods [37]. While anatomic reconstruction often yields the best results, it may be more invasive than anatomic repair [37]. Ligament reconstruction may offer superior results specifically when there is a high preoperative ATFL-SNR [10].

Operative techniques include open and arthroscopic approaches, as well as direct repair or reconstruction using autograft or allograft [31]. Arthroscopic lateral ankle ligament repair yields favorable short-term clinical outcomes [15, 22]. When feasible, arthroscopic repair produces similarly favorable outcomes compared to open lateral ankle repair [33]. Open and arthroscopic ligament repair produced excellent comparable clinical outcomes at 5 years follow-up [23]. Endoscopic ligament reconstruction is a safe procedure that produces good clinical results with minimal complications [20]. It is likely that arthroscopic rather than open lateral ankle ligament repair will become the standard of care in the future [22]. However, arthroscopic techniques require further evaluation to better determine indications and long-term outcomes [32].

The current recommendation is for open anatomic repair or reconstruction [29]. A simple non-augmented repair is acceptable with a high success rate for selected individuals with good indications [26]. If disruption of the lateral ligaments is noted at operation, repair is indicated as it markedly increases the chances for a stable ankle [6]. Lateral ligament augmentation demonstrates superior mechanical stability and functional outcomes compared to the modified Broström repair in treating chronic lateral ankle instability [47]. When compared with lateral ankle repair, anatomic allograft reconstruction produced similarly favorable outcomes, including high patient satisfaction, high function and activity levels, and no revision surgeries in either cohort [73]. The reconstructive armamentarium is detailed along with outcomes and potential complications to guide surgeons in the most appropriate treatment for their patients [46].

Anatomy & Pathophysiology

Ligament Anatomy and Injury Mechanisms

Inversion of the foot is the most common mechanism of injury to the ankle ligaments [70]. In this inversion mechanism, the anterior talofibular ligament is the first or only ligament to sustain injury [70]. A total rupture of the lateral ankle ligaments involves the calcaneofibular ligament and the posterior talofibular ligaments [70]. Conversely, an eversion injury causes damage to the deltoid ligaments [70], while hyperdorsiflexion trauma might cause an injury to the syndesmotic ligaments [70].

The anterior talofibular ligament consists of distinct fascicles with specific anatomical relationships. The inferior fascicle is connected to the calcaneofibular ligament [156]. The superior fascicle is an intra-articular structure [156]. The intra-articular position of an injured anterior talofibular ligament superior fascicle is thought to impair healing [156].

Pathophysiology of Chronic Instability

Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments [70]. The dynamic congruency of the joint, which is influenced by ligamentous integrity, remains the main anatomical component in mechanical ankle instability [84]. Three-dimensional talar shape is not a factor in chronic mechanical ankle instability [84].

Cellular and sensorimotor changes characterize chronic instability. Apoptosis occurs in the anterior talofibular ligament of patients with chronic lateral ankle instability [184]. The number of mechanoreceptors is negatively correlated with ankle sensorimotor dysfunction in chronic ankle joint instability [106]. Patients with chronic ankle instability have longer electromechanical delay times in neutral but not when the ankle is placed in inversion [104].

Kinematic alterations extend beyond the ankle joint. Alterations of kinematics in athletes with chronic ankle instability are found not only at the ankle but also at hip joints during the side-cutting movement [89]. Individuals with chronic ankle instability display different ankle joint coupling patterns and coordination variability during a walking gait cycle compared to copers and controls [111]. Athletes with chronic ankle instability demonstrate dynamic stability deficits, and the direction of the jump can affect dynamic postural stability in the sagittal and frontal planes [128].

Landing strategies and balance are compromised. Single-leg drop landing movement strategies in participants with chronic ankle instability are altered compared to lateral ankle sprain copers [130]. These alterations in landing movement strategies may be responsible for the increased risk of injury experienced by individuals with chronic ankle instability during landing manoeuvres [130]. Dynamic balance deficits in individuals with chronic ankle instability are attested to reduced sagittal plane motions at the hip, knee and ankle joints, and reduced capacity of the stance limb to avail of its supporting base [96].

Osseous morphology may contribute to susceptibility. Most studies found distinct characteristics of the incisura fibularis morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement [107]. Further investigations are required to clarify the characteristic foot and ankle malalignment in chronic ankle instability [94].

Biomechanics and Stability

Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus [125]. Sectioning of the deltoid ligament resulted in a 43% increase in tibiotalar contact area while peak pressures increased 30% [135]. Sectioning of the deltoid ligament alone results in valgus tilt of the talus and therefore chronic instability, which may lead to tibiotalar arthrosis [135].

The accessory anteroinferior tibiofibular ligament is a normal anatomical finding that could lead to anterolateral impingement in cases with coexistent ankle instability [127]. The peroneal tendons play a role in the passive stabilisation of the ankle joint [98]. The MLPP system is capable of measuring anterior talofibular ligament strain patterns to determine the relationship between limb position and ligament strain [115].

Diagnostic measurements vary with position and modality. Plantar flexion of the ankle produces changes in radiographic measurements of the medial clear space [91]. Ultrasound can reliably measure the medial clear space of the ankle while doing dynamic stress manoeuvres [101]. No significant difference was detected between the contralateral healthy ankles of subjects with ipsilateral mechanical lateral ankle laxity and those of bilateral healthy controls [137].

Surgical Biomechanics and Reconstruction Outcomes

The anterior talofibular ligament–posterior talofibular ligament angle decreases after ankle lateral stabilization surgery [28]. It is possible to restore ankle stability with anatomical reconstruction without impairing the range of movement in the ankle joint complex [88]. Approximate ankle kinematic patterns and sufficient laxity, even with an initial tension of 10 N, could be obtained immediately after anterior talofibular ligament reconstruction [83]. Ankle kinematic patterns and laxity after calcaneofibular ligament reconstruction tended to become more abnormal as the initial graft tension increased at the time of surgery [90].

Both arthroscopic and open repair techniques appear biomechanically equivalent in their ability to restore ankle stability [87, 97]. The Brostrom-Gould procedure re-establishes ankle stability in patients with chronic ankle instability, with no significant differences in kinematic patterns or range of motion between reconstructed and contralateral uninjured ankles [117]. Lateral ankle ligament reconstruction with an allograft using 1 fibular tunnel demonstrated similar biomechanical stability to the 2-tunnel approach [118]. The interference screw provides superior biomechanical properties for free tendon reconstruction of the anterior talofibular ligament [122].

For multiligamentous and syndesmotic injuries, combined approaches yield specific outcomes. A combined repair or a combination of repair and bracing closely restored rotational stiffness and ankle stability in case of a multiligamentous ankle injury in a cadaveric model [129]. A novel anatomical reconstruction technique using autogenous peroneus brevis tendon restores syndesmotic biomechanics comparable to the intact state, outperforming 3.5 mm tricortical screw fixation in restoring physiologic stability [133]. Tibiocalcaneal augmentation of deltoid ligament repair has a strong stabilizing effect on the ankle joint [110]. Anatomic suture-button fixation achieved the closest biomechanical parameters to those of the intact ankle model for tibiofibular syndesmosis injuries [95]. The operative ankle exhibited greater syndesmosis length and altered kinematics compared to the healthy side during all tested activities following syndesmosis repair [85].

Classification

Anatomical Integrity: A total rupture of the lateral ligaments involves the calcaneofibular ligament and the posterior talofibular ligaments [70]. The anterior talofibular ligament is the most frequently ruptured and most important component of the lateral ligaments of the ankle [151]. Anatomically, the superior fascicle of the anterior talofibular ligament is distinct from the inferior anterior talofibular ligament fascicle [150]. The inferior anterior talofibular ligament fascicle shares features with the calcaneofibular ligament to form the lateral fibulotalocalcaneal ligament complex [150].

Clinical Grading: Clinical suspicion of lateral ligament injury is scored on a four-grade scale ranging from Grade 0 (intact ligament) to Grade 3 (complete discontinuity with loss of integrity) [48]. Clinical suspicion of lateral ligament injury is considered positive when scored as Grade 3 [48].

Other Considerations: Grading of the three major ligamentous complexes and individual ankle ligaments according to the Schneck grading system resulted in limited diagnostic reliability on 3 T MRI [102].

Clinical Presentation

Chronic ankle instability is defined by ongoing symptoms persisting for at least 6 months, characterized by recurrent sprains, pain, and impairments with perceived instability during sportive activity [92]. A detailed history of the patient's complaints is essential to differentiate between instability resulting from recurrent ligament injury and functional instability not related to increased ligament laxity [60]. Surgical treatment for chronic lateral ankle instability is recommended when patients exhibit symptoms after 3 to 6 months of nonsurgical treatment and physical examination reveals tenderness [86].

Physical examination must include an assessment for generalised ligamentous laxity and of overall lower extremity alignment, particularly hindfoot varus malalignment, which may result in a high likelihood of failure of surgical repair or reconstruction if not addressed [60]. The range of motion (passive and active) of the ankle and subtalar joints is noted during clinical assessment, and gastrocnemius tightness is assessed [60].

Stability testing confirms unilateral mechanical ankle instability using the anterior talar drawer and talar tilt test [92]. The anterior drawer test and hindfoot inversion tests are specifically used to assess for lateral ligament laxity [60]. Ultrasound has manifested high diagnostic accuracy in diagnosing chronic lateral ankle ligament injury [113]. Clinical suspicion of lateral ligament injury is scored on a four-grade scale, where Grade 0 indicates an intact ligament and Grade 3 indicates complete discontinuity with loss of integrity [48].

The presence of intra-articular pathology is recommended to be evaluated by arthroscopy at the time of surgery unless excluded by MRI scan and there is no history of pain [63]. When treating chronic lateral ankle instability, surgeons should consider ligament quality, specifically the anterior talofibular ligament remnant quality, for achieving a stable ankle [66]. 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 [58]. Diagnostics and treatment for lateral ligament instability should consider the deltoid ligament complex, especially the transverse calcaneonavicular ligament [100].

Investigations

MRI: Preoperative MRI serves as a reliable and valid decision-making tool for selecting the surgical stabilization technique in patients with chronic lateral ankle instability [158]. The modality plays an increasingly important role in diagnosing a wide range of foot and ankle abnormalities and planning their surgical treatment [165]. To improve diagnostic accuracy for anterior talofibular ligament injury, the oblique axial-coronal plane can be added to the standard MRI scanning protocol [166]. Isolated injury to the superior fascicle identified on MRI may be useful when diagnosing patients presenting with symptoms of subtle instability without overt ankle laxity on clinical examination [174]. A transformer-based multilabel deep learning model was able to detect lateral and medial collateral ligament injuries based on MRI and outperformed CNN-based models [162].

Point-of-care ultrasound: Point-of-care ankle ultrasound is as precise as MRI for detecting major ankle ligament and Achilles tendon injuries [176].

CT: CT and MRI are excellent imaging modalities that can help the timely diagnosis and appropriate treatment for combined impingement with circumferential lesions [172]. Dixon et al. described an excentric lesion, a symptomatic anterolateral exostosis at the insertion of the anterior talofibular ligament, found by a CT scan in patients with chronic ankle pain after an inversion injury [57]. Anatomic lateral ligament reconstruction using allograft led to accurate tunnel positioning as confirmed by 3D-CT [16].

Plain radiography: With mechanical instability, stress radiographs show 8 to 10 degrees of increased tilt of the talus in the ankle mortise compared with the normal ankle [57]. However, stress radiography did not distinguish between intact and single-ligament disruption and was unreliable in distinguishing between sequential transection models [72]. Radiographic measurements demonstrated excellent agreement among reviewers and across trials, suggesting clinical reproducibility and surgical utility of the defined parameters [175]. Physical examination and oblique radiographs were suggestive of the excentric lesion described by Dixon et al. in most cases [57].

Radiographic Findings: The ATFL–PTFL angle decreases after ankle lateral stabilization surgery [28]. Radiologic residual laxity showed greater varus with isolated direct repair [18]. There was a positive correlation between varus laxity pre-operatively and at follow-up [18]. Patients with greater osteoarthritis showed significantly greater radiologic varus laxity at follow-up [18]. Post-operative evolution of radiologic lesions showed a decrease in Grade 0 (normal) tibiotalar joint lines from 88% pre-operatively to 77% post-operatively [18]. Post-operative evolution of radiologic lesions showed an increase in Grade 1 (osteophytes without impingement) tibiotalar joint lines from 9% pre-operatively to 18% post-operatively [18]. Post-operative evolution of radiologic lesions showed an increase in Grade 2 (impingement with or without osteophytes) tibiotalar joint lines from 3% pre-operatively to 4% post-operatively [18]. Post-operative evolution of radiologic lesions showed an increase in Grade 3 (complete impingement) tibiotalar joint lines from 0% pre-operatively to 1% post-operatively [18].

Associated Pathology: About 20% of athletes referred for MRI after suffering an acute ankle sprain had evidence of a syndesmotic injury regardless of lateral ligament involvement [152]. More than half of athletes referred for MRI after suffering an acute ankle sprain had evidence of any lateral ligament injury without syndesmotic involvement [152].

Treatment

Non-Operative

Nonsurgical measures, including functional rehabilitation, are the management methods of choice for acute injuries, with surgical intervention reserved for high-demand athletes [67]. Successful treatment of grade II and III acute lateral ankle ligament injuries can be achieved with individualized aggressive, non-operative measures, though acute repair may give better results in professional athletes [27]. The only satisfactory non-operative treatment for injuries to the fibular collateral ligaments of the ankle is immobilization in plaster for at least six weeks [147].

Operative

Indications: Reconstruction of the unstable lateral ligament complex using various operative techniques has a high rate of success [1]. A treatment algorithm for chronic ankle instability is based on expert opinion (level V) rather than on clinical evidence, as there is a lack of high-level evidence studies to determine a treatment protocol [36]. It is important to obtain a detailed history of the patient's complaints to help differentiate between instability due to recurrent ligament injury and functional instability, not related to increased ligament laxity [60]. Physical examination must include an assessment for generalised ligamentous laxity and of overall lower extremity alignment (in particular hindfoot varus malalignment) which, if not addressed at the time of surgery, may result in a high likelihood of failure of surgical repair or reconstruction [60]. The range of motion (passive and active) of the ankle and subtalar joints is also noted and gastrocnemius tightness is assessed [60].

Surgical Approach / Technique: The Broström procedure is the gold standard when anatomic reconstruction of the lateral ankle ligaments is attempted [161]. The goal of anatomic reconstruction is to restore the physiologic anatomy by suturing the ligament itself [161]. Exposure of the lateral ankle ligaments can be achieved through a curved incision from the fibula directed anteriorly or posteriorly [161]. The incision directed posteriorly allows a good exposure of the lateral ligaments but has the disadvantage of not being extendable distally [161]. Many surgeons prefer the curved incision directed anteriorly toward the base of the fourth metatarsal [161]. If preoperative examination of the peroneal tendons resulted in unclear diagnostic findings, it is recommended that the tendons be exposed through the same access to possibly identify and repair existing lesions [161]. Painful accessory ossicles in the area of the lateral ligaments are removed [161]. Screw fixation of the fragments to the distal fibula should be considered for very large accessory ossicles [161]. After reconstruction of the ligament, the ATFL and/or the CFL are reattached to the distal fibula using suture anchors or transosseous sutures [161]. The reconstruction can be reinforced using the extensor retinaculum if required [161]. Restoring the CFL plays a relevant role in lateral ligament repair, however sufficient time for ligament healing should be allowed before inversion stresses are applied [13]. The modified Brostrom procedure with a semi-single ligament reconstruction can provide as much initial stability as the two ligaments reconstruction procedure [42]. Over a 5-year follow-up period, primary MBP produced better pain relief and functional recovery than revision to lateral ankle ligament reconstruction (LALR), despite a higher frequency of intra-articular lesions [25]. The arthroscopic Brostrom procedure is a viable alternative to the open procedure, allowing the surgeon to address both lateral ligament instability and associated intra-articular pathologies without extensive dissection [99]. The novel technique of arthroscopic lateral ligament repair using a knotless suture anchor demonstrated significant clinical improvement and good results at final follow-up [50]. Arthroscopic all-inside ATFL repair with suture augmentation gives excellent results in case of poor ligament tissue remnant quality [187]. The strength of fixation with suture anchors in anatomic reconstruction of the ankle lateral ligaments was equivalent to transosseous tunnel fixation as determined with biomechanical testing [188].

Implant Selection: Anatomic lateral ligament reconstruction using allograft led to excellent clinical outcomes and accurate tunnel positioning as confirmed by 3D-CT [16]. Lateral ligament reconstruction using the AHPLT may be a good surgical option for the treatment of chronic ankle instability [24]. All-arthroscopic technique for anatomic reconstruction for chronic lateral ankle instability leads to good clinical results [54]. The anatomic reconstruction of the ankle lateral ligament complex to treat chronic ankle instability using the arthroscopy combined with the fluoroscopic technique could improve the clinical functions, satisfaction, and reduced pain of patients [61]. This hybrid anatomic lateral ligament reconstruction technique using a peroneus longus autograft to substitute the native ATFL provides an alternative to anatomic reconstruction when direct repair is not possible [105]. The use of the plantaris tendon permits an anatomical reconstruction of the lateral ligaments while avoiding sacrifice of the dynamic effect of the peroneus brevis muscle [40]. Reinforcement of the lateral ligaments using tendon grafts is done in the absence of sufficient local tissue (or by poor quality/quantity of local tissue) or by revision surgery [161]. Symptomatic chronic lateral ankle instability could be successfully managed with this easy and effective surgical reconstruction method [51]. The current reconstruction method led to a satisfactory clinical and functional midterm outcome shown by a numeric scale [79]. Carbon fibre reinforcement for chronic lateral ankle instability has the advantage of preservation of inversion, maintenance of peroneal function and simplicity of insertion; in addition the implant does not stretch so the result will not deteriorate with time [78]. Use of the LARS is a viable option in patients for whom the MBG procedure is relatively contraindicated [148]. Surgical resection of the DF-AITFL and ligament reconstruction, when necessary, resulted in significant symptom improvement [55].

Revision: Revision lateral ankle ligament reconstruction (LALR) improves symptoms but outcomes reflect the revision context rather than indicating the procedure is inferior [21].

Other Considerations: Postural control was improved by reconstructing the lateral ligaments [45]. MRI assessment of tendon graft after lateral ankle ligament reconstruction suggests an evolution in graft properties and supports the possibility of creating a viable ligament [44]. 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 [74]. The 80 different surgical interventions and variants found in the literature to treat chronic lateral ankle instability are a sign of the lack of consensus for technical management [12]. Short and intermediate term results for surgical interventions for chronic lateral ankle instability are good or very good in between 80 and 95% of cases [12]. There are very few long-term results evaluating stability and its articular effects in the literature [12]. Three main types of surgical procedures can be identified: tightening of the ligament and capsular tissue, tightening associated with reconstruction and tendon grafts using all or part of the tendon (mainly the peroneus brevis) [12]. The immediate danger of ligamentoplasty procedures are both cutaneous, to avoid extensive subcutaneous detachment (which is why it is important to conserve the inframalleolar fat pad) and neurological because of possible injury to the superficial terminal branches of the sural nerve and the superficial fibular nerve [12]. The anatomical repairs are still the best methods of treatment in symptomatic chronic instability and with the high incidence of intra-articular pathology it is recommended that an arthroscopy is performed at the time of surgery unless intra-articular pathology has been excluded by MRI scan and there is no history of pain [63]. An excellent or good result was achieved in 132 ankles, all of which had improved mechanical stability as measured radiographically [8]. ALALR can produce favorable clinical outcomes in the short term, and it is likely that arthroscopic rather than open lateral ankle ligament repair will become the standard of care in the future [22].

Complications

Nerve Injury: The immediate danger of lateral ligamentoplasty procedures includes neurological injury to the superficial terminal branches of the sural nerve and the superficial fibular nerve [12]. 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 [171]. In a study of arthroscopic all-inside anterior talofibular ligament repair, 2 patients in the inferior extensor retinaculum reinforcement group experienced superficial peroneal nerve injuries, with symptoms subsiding by 3 months [163]. One patient in each group of an arthroscopic all-inside anterior talofibular ligament repair study presented with neuralgia of the superficial peroneal nerve, which improved over time without treatment [171]. In a cohort of 20 patients undergoing anatomic reconstruction with a semitendinosus allograft, one patient experienced superficial peroneal neurapraxia that resolved and a sural nerve injury that did not recover [181]. In the same cohort of 20 patients undergoing anatomic reconstruction with a semitendinosus allograft, a second patient experienced sural neurapraxia that resolved [181]. In a study of arthroscopic allograft reconstruction for chronic lateral ankle instability, 9.1% of patients experienced minor neurologic complications [80]. In a study of anatomic repair for anterior talofibular ligament injury at the talar side, no patient had superficial peroneal nerve injury [169].

Wound and Infection Complications: The immediate danger of lateral ligamentoplasty procedures includes cutaneous complications, necessitating the avoidance of extensive subcutaneous detachment and conservation of the inframalleolar fat pad [12]. In a cohort of 20 patients undergoing anatomic reconstruction with a semitendinosus allograft, one patient developed a local wound infection with skin slough, which resolved with oral antibiotics and local wound care [181]. One patient in the no-inferior extensor retinaculum reinforcement group of an arthroscopic repair study presented with an abscess requiring local incision and drainage [171]. The minimally invasive nature of percutaneous calcaneal osteotomy combined with arthroscopic lateral ankle ligament reconstruction presents a lower infection risk [199].

Hardware and Suture Complications: In a study of arthroscopic all-inside anterior talofibular ligament repair, one patient in the inferior extensor retinaculum reinforcement group had suture knot irritation around the acAL portal, which improved after knot excision under local anesthesia [163]. Two patients in the inferior extensor retinaculum reinforcement group of an arthroscopic all-inside anterior talofibular ligament repair study had knot irritation causing mild discomfort [171]. In a study of anatomic repair for anterior talofibular ligament injury at the talar side, no patient had knot reaction [169]. Complications of arthroscopic lateral ankle repair include pain or discomfort arising from a prominent anchor or suture knot [163].

Recurrence and Instability: In a study of arthroscopic all-inside anterior talofibular ligament repair, 8.1% of patients in the repair group and 6.7% of patients in the augmentation group had anterior talofibular ligament retear on MRI [163]. All patients who had anterior talofibular ligament retear on MRI in the arthroscopic repair study had recurrent chronic ankle instability with functional discomfort and anterior displacement greater than 3 mm compared with the other ankle [163]. In a study of anatomic repair for anterior talofibular ligament injury at the talar side, 6 patients (15.4%) suffered recurrent sprain after return to sport [169]. The presence of one or more risk factors should influence the surgical strategy to mitigate the risk of treatment failure after lateral ankle ligament repair [198]. Concomitant ankle arthroscopy procedures performed with ankle ligament procedures did not decrease the rate of reoperation [196].

Functional Limitations and Pain: Reduced tibiotalar dorsiflexion significantly reduced the number of good and very good results in a long-term review of peroneus brevis ligamentoplasty, and was the only apparent cause of poor results [123]. In a study of anatomic repair for anterior talofibular ligament injury at the talar side, ROM deficiency was found in eight patients (25%) with a feeling of ankle stiffness [169]. Of the eight patients with ROM deficiency in the talar-side ATFL repair study, five presented with 5–10 degrees of dorsiflexion limitation and three presented with 5–10 degrees of inversion limitation [169]. In a long-term prospective study of chronic lateral ankle instability surgical repairs, Karlsson scores were significantly poorer with Castaing peroneus brevis plasty, principally due to the "pain" and "residual instability" components [18]. In the same long-term prospective study, radiologic residual laxity showed greater varus with isolated direct repair [18]. In the same long-term prospective study, patients with greater osteoarthritis showed significantly greater radiologic varus laxity at follow-up [18].

General Complication Rates: The wide variations in the reported complication rates for arthroscopic lateral ankle repair range from 0% to 29% [171]. The complications of arthroscopic lateral ankle repair include nerve pain, knot irritation, delayed wound-healing, and deep vein thrombosis [171]. In a study of arthroscopic all-inside anterior talofibular ligament repair with and without inferior extensor retinacular reinforcement, there were no other complications in the repair group besides those noted [163]. In a study of anatomic repair for anterior talofibular ligament injury at the talar side, no patient had infection or revision surgery [169]. In a study of immediate weightbearing after augmented modified Broström reconstruction, most patients achieved excellent functional outcomes by 6 weeks with minimal complications [71]. In a study of surgical fibular tendon stabilisation by isolated re-tensioning of the superior fibular retinaculum, the technique is associated with a very low complication rate [81].

Recovery

Light activity (weeks): Most patients achieve excellent functional outcomes by 6 weeks following an accelerated rehabilitation protocol after augmented modified Broström reconstruction, with minimal complications and high satisfaction [71]. Immediate weightbearing is a safe and practical postoperative rehabilitation method that can be applied after arthroscopic lateral ankle ligament repair [138].

Full activity (months): Patients with chronic lateral ankle instability who underwent arthroscopic allograft reconstruction successfully returned to preinjury occupations within 5 months and sports within 9 months [80]. In a cohort of patients with chronic lateral ligament instability treated with plication and extensor digitorum brevis transfer, all 30 patients returned to normal sporting activity, including National Championships and Olympic representation [59]. All patients were able to return to their normal occupations after operation for lateral ligament reconstruction [170]. Good patient-reported outcomes as well as excellent return to sport and return to work rates can be achieved in high-risk patients undergoing ankle ligament reconstruction with a tendon autograft for chronic lateral ankle instability [68].

Rehabilitation protocol: An accelerated rehabilitation pathway after modified Broström repair is supported by findings indicating safety and efficacy in both athletic and general populations [144].

Functional milestones: 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 [146].

Other Considerations: Distal rupture near the talar or calcaneal end of the lateral ankle ligament was associated with delayed return-to-sport and inferior performance in resuming pre-injury sports level [189]. There is fair evidence showing a worse clinical outcome score in combined ligament ruptures, as well as a decreased return to full sports activities [190]. A systematic review identifies a clear deficiency in the literature pertaining to consistent, meaningful postoperative return to sport timeline following lateral ankle ligament repair [49]. In a small group of patients undergoing lateral ankle stabilization after distal fibular resection, patients were able to return to normal daily activities without instability or progression to tibiotalar arthrosis at short term [145].

Key Evidence

• [L5] Reconstruction of the unstable lateral ligament complex with use of a variety of operative techniques has had a high rate of success. [1] (10.2106/00004623-199407000-00021)
• [Paper] Anatomic ligament repair with reinforcement or anatomic ligament reconstruction are the two recommended options for lateral ligament reconstruction. [2] (10.1016/j.otsr.2016.06.026)
• [L4] Lateral ligament reconstruction with allograft represents a valid treatment option in patients with severe chronic lateral ankle instability, leading to satisfying outcomes and reduced joint morbidity. [3] (10.1007/s00402-013-1911-6)
• [L1] Reconstruction of the lateral ankle ligament is a relatively stable treatment for chronic ankle instability. [4] (10.1016/j.injury.2020.05.031)
• [L3] Satisfactory clinical outcomes can be achieved through both arthroscopic and percutaneous anatomic ligament reconstruction. [5] (10.1186/s13018-024-05251-4)
• [L4] If disruption of the lateral ligaments is noted at operation, repair is indicated as it markedly increases the chances for a stable ankle. [6] (10.2106/00004623-198971090-00018)
• [L4] An excellent or good result was achieved in 132 ankles, all of which had improved mechanical stability as measured radiographically. [8] (10.2106/00004623-198870040-00015)
• [L5] The purpose of this presentation is to review what has been established for chronic lateral ankle instability and discuss the arthroscopic lateral ligament repair technique. [9] (10.1177/2325967119s00452)
• [L3] However, ligament reconstruction may offer superior results when there is a high preoperative ATFL-SNR. [10] (10.1177/03635465251383564)
• [L5] The commonly cited data in favor of not repairing the deltoid ligament warrants careful consideration to allow accuracy in obtaining the best patient outcomes with the most predictable surgical methods available. [11] (10.5435/jaaos-d-20-00323)
• [Paper] [12] (10.1016/j.otsr.2010.04.005)
• [L5] Restoring the CFL plays a relevant role in lateral ligament repair, however sufficient time for ligament healing should be allowed before inversion stresses are applied. [13] (10.1016/j.arthro.2017.04.065)
• [L4] The current systematic review demonstrated that arthroscopic lateral ankle ligament repair yields favorable clinical outcomes in the short term. [15] (10.1016/j.arthro.2018.02.034)
• [L4] Anatomic lateral ligament reconstruction using allograft led to excellent clinical outcomes and accurate tunnel positioning as confirmed by 3D-CT. [16] (10.1016/j.otsr.2018.10.008)
• [L4] Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon can be a surgical option for chronic lateral ankle instability with attenuated or deficient ligaments. [17] (10.1007/s00167-014-3072-8)
• [L4] [18] (10.1016/j.otsr.2010.04.004)
• [L2] Endoscopic ligament reconstruction for chronic lateral ankle instability is a safe procedure that produces good clinical results with minimal complications. [20] (10.1007/s00167-019-05793-9)
• [Paper] The editorial commentary concludes that revision lateral ankle ligament reconstruction (LALR) improves symptoms but outcomes reflect the revision context rather than indicating the procedure is inferior. [21] (10.1002/arj.70376)
• [L5] ALALR can produce favorable clinical outcomes in the short term, and it is likely that arthroscopic rather than open lateral ankle ligament repair will become the standard of care in the future. [22] (10.1016/j.arthro.2018.05.001)
• [L3] Open and arthroscopic ligament repair produced excellent comparable clinical outcomes at 5 years follow-up. [23] (10.1007/s00167-023-07621-7)
• [L4] Lateral ligament reconstruction using the AHPLT may be a good surgical option for the treatment of chronic ankle instability. [24] (10.1177/0363546516675167)
• [L3] Over a 5-year follow-up period, primary MBP produced better pain relief and functional recovery than revision to lateral ankle ligament reconstruction (LALR), despite a higher frequency of intra-articular lesions. [25] (10.1002/arj.70354)
• [L5] A simple non-augmented repair is acceptable with a high success rate for selected individuals with good indications. [26] (10.1177/2325967124s00376)
• [L4] Successful treatment of grade II and III acute lateral ankle ligament injuries can be achieved with individualized aggressive, non-operative measures, though acute repair may give better results in professional athletes. [27] (10.1007/s00167-012-2252-7)
• [L3] The ATFL–PTFL angle decreases after ankle lateral stabilization surgery. [28] (10.1007/s00167-020-06174-3)
• [L5] The current recommendation is for open anatomic repair/reconstructions. [29] (10.1016/j.csm.2020.07.004)
• [L4] Surgical procedures for managing chronic lateral ankle instability include anatomic direct repair, anatomic reconstruction with an autograft or allograft, and arthroscopic repair. [31] (10.5435/jaaos-d-16-00623)
• [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. [32] (10.1016/j.otsr.2018.09.005)
• [L3] When compared with open lateral ankle repair, arthroscopic repair of lateral ankle ligament when feasible produced similarly favorable outcomes. [33] (10.1177/0363546517698675)
• [L5] [36] (10.1007/s00167-017-4556-0)
• [L4] Anatomic reconstruction seems to give the best results, but may be more invasive than anatomic repair. [37] (10.1007/s00167-017-4730-4)
• [L4] The use of the plantaris tendon permits an anatomical reconstruction of the lateral ligaments while avoiding sacrifice of the dynamic effect of the peroneus brevis muscle. [40] (10.2106/00004623-198567060-00016)
• [L5] The modified Brostrom procedure with a semi-single ligament reconstruction can provide as much initial stability as the two ligaments reconstruction procedure. [42] (10.1007/s00167-008-0557-3)
• [L3] This is important for clinical practice, as it suggests an evolution in graft properties and supports the possibility of creating a viable ligament. [44] (10.1177/03635465231225487)
• [L4] Postural control was improved by reconstructing the lateral ligaments. [45] (10.1007/s00167-015-3660-2)
• [L5] The reconstructive armamentarium is detailed along with outcomes and potential complications to guide surgeons in the most appropriate treatment for their patients. [46] (10.5435/jaaos-d-20-00802)
• [L1] Lateral ligament augmentation demonstrates superior mechanical stability and functional outcomes compared to the modified Broström repair in treating CLAI. [47] (10.1186/s13018-025-06637-8)
• [L3] [48] (10.1002/ksa.12079)
• [L4] The review identifies a clear deficiency in the literature pertaining to consistent, meaningful postoperative return to sport timeline following lateral ankle ligament repair. [49] (10.1136/jisakos-2016-000064)
• [L4] The novel technique of arthroscopic lateral ligament repair using a knotless suture anchor demonstrated significant clinical improvement and good results at final follow-up. [50] (10.1177/2325967120962079)
• [L4] Symptomatic chronic lateral ankle instability could be successfully managed with this easy and effective surgical reconstruction method. [51] (10.1016/j.injury.2003.09.035)
• [L4] All-arthroscopic technique for anatomic reconstruction for chronic lateral ankle instability leads to good clinical results. [54] (10.1016/j.arthro.2017.08.159)
• [L4] Surgical resection of the DF-AITFL and ligament reconstruction, when necessary, resulted in significant symptom improvement. [55] (10.1177/23259671241275959)
• [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. [58] (10.2106/jbjs.21.00726)
• [L4] All 30 patients with chronic lateral ligament instability returned to normal sporting activity, including National Championships and Olympic representation. [59] (10.1016/0020-1383(88)90073-3)
• [L5] [60] (10.1007/s00167-015-3789-z)
• [L4] The anatomic reconstruction of the ankle lateral ligament complex to treat chronic ankle instability using the arthroscopy combined with the fluoroscopic technique could improve the clinical functions, satisfaction, and reduced pain of patients. [61] (10.1186/s12891-021-04165-0)
• [L4] [63] (10.1016/j.otsr.2013.10.009)
• [L4] Therefore, when treating chronic lateral ankle instability, surgeons should consider ligament quality. [66] (10.1007/s00167-022-07211-z)
• [L5] Nonsurgical measures, including functional rehabilitation, are the management methods of choice for acute injuries, with surgical intervention reserved for high-demand athletes. [67] (10.5435/00124635-200810000-00006)
• [L4] Good patient-reported outcomes as well as excellent RTS and RTW rates can be achieved in high-risk patients undergoing ankle ligament reconstruction with a tendon autograft for CLAI. [68] (10.1007/s00167-022-06937-0)
• [L5] [70] (10.1007/s00167-010-1100-x)
• [L4] Most patients achieved excellent functional outcomes by 6 weeks, with minimal complications, high satisfaction, and return to sport before 1 year. [71] (10.1177/23259671251389196)
• [L5] Stress radiography did not distinguish between intact and single-ligament disruption and was unreliable in distinguishing between sequential transection models. [72] (10.1016/j.arthro.2016.11.008)
• [L3] When compared with lateral ankle repair, anatomic allograft reconstruction produced similarly favorable outcomes, including high patient satisfaction, high function and activity levels, and no revision surgeries in either cohort. [73] (10.1177/0363546515627817)
• [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. [74] (10.1136/jisakos-2018-000265)
• [L4] They have the advantage of preservation of inversion, maintenance of peroneal function and simplicity of insertion; in addition the implant does not stretch so the result will not deteriorate with time. [78] (10.1016/0020-1383(88)90169-6)
• [L4] The current reconstruction method led to a satisfactory clinical and functional midterm outcome shown by a numeric scale. [79] (10.1097/01.blo.0000128645.84131.af)
• [L4] Patients with CLAI who underwent arthroscopic allograft reconstruction successfully returned to preinjury occupations within 5 months and sports within 9 months, showing excellent clinical outcomes with 100% achieving minimal clinically important difference in scores at minimum 24-month follow-up, though 9.1% experienced minor neurologic complications. [80] (10.1016/j.arthro.2025.01.037)
• [L4] This simple and reproducible technique is associated with a very low complication rate and with excellent functional and anatomical outcomes. [81] (10.1016/j.otsr.2016.12.004)
• [L5] Approximate ankle kinematic patterns and sufficient laxity, even with an initial tension of 10 N, could be obtained immediately after ATFL reconstruction. [83] (10.1177/0363546520902725)
• [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. [84] (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. [85] (10.2106/jbjs.20.01787)
• [L1] [86] (10.1177/2325967119873852)
• [L5] Both techniques were shown to be comparable to the intact state suggesting that biomechanically effective ankle stabilizations may be able to be performed through a minimally invasive approach. [87] (10.1016/j.arthro.2011.03.061)
• [L3] The results of the study show that it is possible to restore ankle stability with anatomical reconstruction without impairing the range of movement in the ankle joint complex. [88] (10.1007/s00167-004-0562-0)
• [L3] Alterations of kinematics in athletes with chronic ankle instability were found not only at the ankle but also at hip joints during the side-cutting movement. [89] (10.1007/s00167-015-3745-y)
• [L5] Ankle kinematic patterns and laxity after CFL reconstruction tended to become more abnormal as the initial graft tension increased at the time of surgery. [90] (10.1177/0363546518790254)
• [L4] Plantar flexion of the ankle produces changes in radiographic measurements of the medial clear space. [91] (10.2106/jbjs.i.00084)
• [L4] [92] (10.1186/s13018-020-01847-8)
• [L1] Further investigations are required to clarify the characteristic foot and ankle malalignment in CAI to facilitate the development of efficient interventions. [94] (10.1186/s12891-021-04537-6)
• [L3] Anatomical suture-button (ANSB) fixation achieved the closest biomechanical parameters to those of the intact ankle model. [95] (10.1186/s12891-026-09681-5)
• [L3] This was attested to reduced sagittal plane motions at the hip, knee and ankle joints, and reduced capacity of the stance limb to avail of its supporting base. [96] (10.1007/s00167-015-3744-z)
• [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. [97] (10.5435/jaaos-d-20-00145)
• [L5] [98] (10.1007/s00167-012-2273-2)
• [Paper] The arthroscopic Brostrom procedure is a viable alternative to the open procedure, allowing the surgeon to address both lateral ligament instability and associated intra-articular pathologies without extensive dissection. [99] (10.1016/j.eats.2016.03.003)
• [L5] Diagnostics and treatment for lateral ligament instability should consider the deltoid ligament complex, especially the TCL. [100] (10.1007/s00167-013-2708-4)
• [L3] Ultrasound can reliably measure the medial clear space of the ankle while doing dynamic stress manoeuvres. [101] (10.5435/jaaos-d-20-00597)
• [L4] Grading of the three major ligamentous complexes and of the individual ankle ligaments according the Schneck grading system resulted in limited diagnostic reliability. [102] (10.1136/jisakos-2020-000503)
• [L3] Patients with chronic ankle instability had longer electromechanical delay times in neutral but not when the ankle was placed in inversion. [104] (10.1007/s00167-016-4243-6)
• [L4] This hybrid anatomic lateral ligament reconstruction technique using a peroneus longus autograft to substitute the native ATFL provides an alternative to anatomic reconstruction when direct repair is not possible. [105] (10.1177/0363546512455397)
• [L5] The number of mechanoreceptors was negatively correlated with ankle sensorimotor dysfunction. [106] (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. [107] (10.1016/j.jisako.2024.100361)
• [L5] While this surgical technique may be technically challenging, it has a strong stabilizing effect on the ankle joint. [110] (10.1177/03635465251352739)
• [L3] The CAI, coper, and control groups displayed different ankle joint coupling patterns and coordination variability during a walking gait cycle. [111] (10.1177/23259671221139482)
• [L1] Ultrasound manifested high diagnostic accuracy in diagnosing chronic lateral ankle ligament injury. [113] (10.1186/s13018-018-0811-4)
• [L5] The MLPP system is capable of measuring ATFL strain patterns; thus, this system may be used to effectively determine the relationship between limb position and ATFL ankle ligament strain patterns. [115] (10.1186/s12891-021-04058-2)
• [L4] The Brostrom-Gould procedure re-establishes ankle stability in patients with chronic ankle instability, with no significant differences in kinematic patterns or range of motion between reconstructed and contralateral uninjured ankles. [117] (10.1016/j.arthro.2013.07.054)
• [L5] Lateral ankle ligament reconstruction with an allograft using 1 fibular tunnel demonstrated similar biomechanical stability to the 2-tunnel approach. [118] (10.1177/2325967120959284)
• [L5] The study concludes that the interference screw provides superior biomechanical properties for free tendon reconstruction of the anterior talofibular ligament. [122] (10.1177/0363546504265051)
• [Paper] [123] (10.1016/j.otsr.2013.12.003)
• [L5] Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus. [125] (10.2106/00004623-199607000-00006)
• [L5] Although it reflects a normal anatomical finding, it could lead to anterolateral impingement in cases with coexistent ankle instability. [127] (10.1177/0095399703258697)
• [L3] Athletes with chronic ankle instability demonstrated dynamic stability deficits, and the direction of the jump can affect dynamic postural stability in the sagittal and frontal planes. [128] (10.1186/s12891-025-09307-2)
• [L5] A combined repair or a combination of repair and bracing closely restored rotational stiffness and ankle stability in case of a multiligamentous ankle injury in a cadaveric model. [129] (10.1177/03635465251361148)
• [L3] These alterations may be responsible for the increased risk of injury experienced by individuals with CAI during landing manoeuvres. [130] (10.1007/s00167-015-3852-9)
• [L5] The novel anatomical reconstruction technique using autogenous peroneus brevis tendon restores syndesmotic biomechanics comparable to the intact state, outperforming 3.5 mm tricortical screw fixation in restoring physiologic stability. [133] (10.1007/s00167-017-4485-y)
• [L4] No significant difference was detected between the contralateral healthy ankles of subjects with ipsilateral mechanical lateral ankle laxity and those of bilateral healthy controls. [137] (10.1186/s12891-022-05838-0)
• [L1] Immediate weightbearing is a safe and practical postoperative rehabilitation method that can be applied after arthroscopic lateral ankle ligament repair. [138] (10.1177/03635465241289946)
• [L4] These findings support the safety and efficacy of an accelerated rehabilitation pathway after modified Broström repair and justify its use in both athletic and general populations. [144] (10.1177/2325967126s00318)
• [L4] In this small group, patients were able to return to normal daily activities without instability or progression to tibiotalar arthrosis at short term. [145] (10.1007/s11999-013-3408-6)
• [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. [146] (10.1177/2325967121s00010)
• [L4] The only satisfactory non-operative treatment is immobilization in plaster for at least six weeks. [147] (10.2106/00004623-196143020-00011)
• [L2] Use of the LARS in this manner is a viable option in patients for whom the MBG procedure is relatively contraindicated. [148] (10.1177/23259671221093968)
• [L5] The superior fascicle of the ATFL is anatomically and functionally distinct from the inferior ATFL fascicle, which shares features with the CFL to form the lateral fibulotalocalcaneal ligament (LFTCL) complex. [150] (10.1007/s00167-018-5188-8)
• [L4] The anterior talofibular ligament is the most frequently ruptured and most important component of the lateral ligaments of the ankle. [151] (10.2106/00004623-194931020-00013)
• [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. [152] (10.1177/0363546514529643)
• [L5] [156] (10.1002/ksa.12538)
• [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. [158] (10.1016/j.arthro.2017.04.066)
• [Paper] [161] (10.1016/j.csm.2015.06.004)
• [L4] The transformer-based model was able to detect lateral and medial collateral ligament injuries based on MRI and outperformed CNN-based models, demonstrating a promising performance in diagnosing CAI, especially patients with RCAI. [162] (10.1016/j.arthro.2024.05.027)
• [L3] [163] (10.1177/03635465211008097)
• [L5] Magnetic resonance imaging of the foot and ankle is playing an increasingly important role in the diagnosis of a wide range of foot and ankle abnormalities and the planning for their surgical treatment. [165] (10.5435/00124635-200105000-00005)
• [L5] The oblique axial-coronal plane could be added to the MRI scanning protocol during clinical practices to improve the diagnostic accuracy of ATFL injury. [166] (10.1186/s13018-019-1102-4)
• [L3] [169] (10.1007/s00167-023-07658-8)
• [L4] All patients were able to return to their normal occupations after operation. [170] (10.1016/0020-1383(75)90065-0)
• [L1] [171] (10.2106/jbjs.20.01696)
• [Case_report] We suggest CT and MRI as excellent imaging modalities that can help the timely diagnosis and appropriate treatment for this combined impingement with circumferential lesions. [172] (10.1186/s12891-020-03584-9)
• [L3] Isolated injury to the superior fascicle identified on MRI may be useful when diagnosing patients presenting with symptoms of subtle instability without overt ankle laxity on clinical examination. [174] (10.1007/s00167-022-07275-x)
• [L5] Radiographic measurements demonstrated excellent agreement among reviewers and across trials suggesting clinical reproducibility and surgical utility of the defined parameters. [175] (10.1177/2325967115s00041)
• [L3] Point-of-care ankle ultrasound is as precise as MRI for detecting major ankle ligament and Achilles tendon injuries; it could be used for immediate diagnosis and further pre-operative imaging. [176] (10.1016/j.injury.2017.07.015)
• [L4] [181] (10.1177/0363546515593942)
• [L5] [184] (10.1097/corr.0000000000002404)
• [L4] [187] (10.1007/s00167-018-5117-x)
• [L5] The strength of fixation with suture anchors in anatomic reconstruction of the ankle lateral ligaments was equivalent to transosseous tunnel fixation as determined with biomechanical testing. [188] (10.1016/j.arthro.2013.08.015)
• [L3] Distal rupture near the talar or calcaneal end was associated with delayed return-to-sport and inferior performance in resuming pre-injury sports level. [189] (10.1186/s12891-022-05260-6)
• [L1] There is, however, fair evidence showing a worse clinical outcome score in the combined ruptures, as well as a decreased return to full sports activities. [190] (10.1007/s00167-021-06610-y)
• [L4] Concomitant ankle arthroscopy procedures performed with ankle ligament procedures did not decrease the rate of reoperation. [196] (10.1007/s00167-016-4207-x)
• [L4] The presence of one or more of these risk factors should influence the surgical strategy to mitigate the risk of treatment failure. [198] (10.1016/j.jisako.2025.100420)
• [L5] The minimally invasive nature of PCO combined with LALAR presents clear advantages, such as reduced trauma, lower infection risk, quicker recovery, and better cosmetic outcomes. [199] (10.1016/j.eats.2024.102989)

See Also

• Chronic ankle instability
• Lateral ankle ligament injury
• Syndesmotic injury
• Ankle arthroscopy

References

[1] Reconstruction of the Lateral Ankle Ligaments. The Journal of Bone & Joint Surgery. 1994. DOI: 10.2106/00004623-199407000-00021

[2] Lateral ligament reconstruction procedures for the ankle. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2016.06.026

[3] Lateral ligament reconstruction with allograft in patients with severe chronic ankle instability. Archives of Orthopaedic and Trauma Surgery. 2013. DOI: 10.1007/s00402-013-1911-6

[4] The effectiveness of lateral ankle ligament reconstruction when treating chronic ankle instability: A systematic review and meta-analysis. Injury. 2020. DOI: 10.1016/j.injury.2020.05.031

[5] Arthroscopically assisted accurate location of the bone tunnel entrance for lateral ankle ligament reconstruction may be a better choice for patients with chronic ankle instability: a retrospective study. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05251-4

[6] Unrecognized injuries of the lateral ligaments associated with lateral malleolar fractures of the ankle.. The Journal of Bone & Joint Surgery. 1989. DOI: 10.2106/00004623-198971090-00018

[8] Reconstruction of the lateral ligaments of the ankle for chronic lateral instability.. The Journal of Bone & Joint Surgery. 1988. DOI: 10.2106/00004623-198870040-00015

[9] Arthroscopic Lateral Ligament Repair. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00452

[10] Comparison of Clinical Outcomes Between Ligament Repair and Reconstruction After Excision of Large Os Subfibulare With Diameter ≥10 mm: A Propensity Score–Matched Analysis. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465251383564

[11] Deltoid Ligament Injuries Associated With Ankle Fractures: Arguments For and Against Direct Repair. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-00323

[12] Chronic ankle instability. Which tests to assess the lesions? Which therapeutic options?. Orthopaedics & Traumatology: Surgery & Research. 2010. DOI: 10.1016/j.otsr.2010.04.005

[13] Arthroscopic Brostrom versus combined repairs of ATFL and CFL: A Biomechanical Comparison of Repair Techniques. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.04.065

[15] Arthroscopic Repair of Lateral Ankle Ligament for Chronic Lateral Ankle Instability: A Systematic Review. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.02.034

[16] Three-Dimensional computed tomography tunnel assessment of allograft anatomic reconstruction in chronic ankle instability: 33 cases. Orthopaedics & Traumatology: Surgery & Research. 2019. DOI: 10.1016/j.otsr.2018.10.008

[17] Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3072-8

[18] Chronic lateral ankle instability surgical repairs: The long term prospective. Orthopaedics & Traumatology: Surgery & Research. 2010. DOI: 10.1016/j.otsr.2010.04.004

[20] 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

[21] Editorial Commentary : Revision Lateral Ankle Ligament Reconstruction Improves Symptoms, but Outcomes Reflect the Revision Context. Arthroscopy. 2026. DOI: 10.1002/arj.70376

[22] Editorial Commentary: Repair of Lateral Ankle Ligament: Is Arthroscopic Technique the Next Station?. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.05.001

[23] Arthroscopic all‐inside ligament repair has similar or superior clinical outcomes compared to open repair for chronic ankle instability without concomitant intra‐articular pathology at 5 years follow‐up. Knee Surgery, Sports Traumatology, Arthroscopy. 2023. DOI: 10.1007/s00167-023-07621-7

[24] Donor Site Morbidity After Lateral Ankle Ligament Reconstruction Using the Anterior Half of the Peroneus Longus Tendon Autograft. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546516675167

[25] Primary Modified Broström Procedure Shows Superior Outcome to Revision to Lateral Ankle Ligament Reconstruction in Patients With Chronic Lateral Ankle Instability at 5‐Year Follow‐Up. Arthroscopy. 2026. DOI: 10.1002/arj.70354

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

[27] Management of acute lateral ankle ligament injury in the athlete. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2252-7

[28] 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

[29] Chronic Lateral Ankle Instability. Clinics in Sports Medicine. 2020. DOI: 10.1016/j.csm.2020.07.004

[31] Surgical Procedures for Chronic Lateral Ankle Instability. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-16-00623

[32] 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] 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

[36] Searching for consensus in the approach to patients with chronic lateral ankle instability: ask the expert. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4556-0

[37] Anatomic stabilization techniques provide superior results in terms of functional outcome in patients suffering from chronic ankle instability compared to non-anatomic techniques. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4730-4

[40] 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

[42] Biomechanical evaluation against calcaneofibular ligament repair in the Brostrom procedure: a cadaveric study. Knee Surgery, Sports Traumatology, Arthroscopy. 2008. DOI: 10.1007/s00167-008-0557-3

[44] MRI Assessment of Tendon Graft After Lateral Ankle Ligament Reconstruction: Does Ligamentization Exist?. The American Journal of Sports Medicine. 2024. DOI: 10.1177/03635465231225487

[45] The improvement of postural control in patients with mechanical ankle instability after lateral ankle ligaments reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3660-2

[46] Management of Anterior Tibialis Tendon Ruptures. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-00802

[47] Efficacy and safety of lateral ligaments augmentation and modified Brostrom repair in the treatment of chronic lateral instability of the ankle joint: a meta-analysis. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-025-06637-8

[48] 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

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

[50] A Novel Technique of Arthroscopic Ankle Lateral Ligament Repair Using a Knotless Suture Anchor. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120962079

[51] Surgical reconstruction for chronic lateral instability of the ankle. Injury. 2004. DOI: 10.1016/j.injury.2003.09.035

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

[55] Characteristics and Outcomes of Surgical Treatment for Anterolateral Ankle Impingement Due to the Distal Fascicle of the Anterior Inferior Tibiofibular Ligament. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/23259671241275959

[57] Campbell S Operative Orthopaedics 4 Volume Set. REPAIR OF ACUTE RUPTURE OF LATERAL LIGAMENTS > CHRONIC INSTABILITY AFTER INJURY.

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

[59] Plication of the anterolateral capsule of the ankle with extensor digitorum brevis transfer for chronic lateral ligament instability. Injury. 1988. DOI: 10.1016/0020-1383(88)90073-3

[60] Arthroscopic anatomical reconstruction of the lateral ankle ligaments. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3789-z

[61] Using arthroscopy combined with fluoroscopic technique for accurate location of the bone tunnel entrance in chronic ankle instability treatment. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04165-0

[63] Consensus in chronic ankle instability: Aetiology, assessment, surgical indications and place for arthroscopy. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2013.10.009

[66] Anterior talofibular ligament remnant quality is important for achieving a stable ankle after arthroscopic lateral ankle ligament repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07211-z

[67] Management of Acute and Chronic Ankle Instability. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200810000-00006

[68] 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

[70] Anatomy of the ankle ligaments: a pictorial essay. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1100-x

[71] 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

[72] Arthroscopic Quantification of Syndesmotic Instability in a Cadaveric Model. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2016.11.008

[73] Activity Level and Function After Lateral Ankle Ligament Repair Versus Reconstruction. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546515627817

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

[78] Carbon fibre reinforcement for chronic lateral ankle instability. Injury. 1988. DOI: 10.1016/0020-1383(88)90169-6

[79] Midterm Results of a Modified Evans Repair for Chronic Lateral Ankle Instability. Clinical Orthopaedics and Related Research. 2004. DOI: 10.1097/01.blo.0000128645.84131.af

[80] Arthroscopic Reconstruction of the Anterior Talofibular Ligament and Calcaneofibular Ligament Using Allograft for Chronic Lateral Ankle Instability Allows Patients to Successfully Return to Their Preinjury Sports Activities With Excellent Clinical Outcome at Minimum 2‐Year Follow‐Up. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.01.037

[81] Functional and ultrasonographic outcomes after surgical fibular tendon stabilisation by isolated re-tensioning of the superior fibular retinaculum. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2016.12.004

[83] Effect of Initial Graft Tension During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In Situ Forces of the Reconstructed Graft. The American Journal of Sports Medicine. 2020. DOI: 10.1177/0363546520902725

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

[85] 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

[86] Clinical Guidelines for the Surgical Management of Chronic Lateral Ankle Instability: A Consensus Reached by Systematic Review of the Available Data. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119873852

[87] A Biomechanical Comparison of an Open vs. Arthroscopic Approach for the Treatment of Lateral Ankle Instability (SS‐57). Arthroscopy. 2011. DOI: 10.1016/j.arthro.2011.03.061

[88] Anatomical repair of lateral ligaments in patients with chronic ankle instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2004. DOI: 10.1007/s00167-004-0562-0

[89] Kinematics and muscle activities of the lower limb during a side-cutting task in subjects with chronic ankle instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3745-y

[90] Effect of Initial Graft Tension During Calcaneofibular Ligament Reconstruction on Ankle Kinematics and Laxity. The American Journal of Sports Medicine. 2018. DOI: 10.1177/0363546518790254

[91] 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

[92] Functional deficits in chronic mechanical ankle instability. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01847-8

[94] Abnormalities of foot and ankle alignment in individuals with chronic ankle instability: a systematic review. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04537-6

[95] Biomechanical comparison of different fixation methods for tibiofibular syndesmosis injuries: a finite element analysis study. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09681-5

[96] Dynamic balance deficits in individuals with chronic ankle instability compared to ankle sprain copers 1 year after a first-time lateral ankle sprain injury. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3744-z

[97] 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

[98] The role of the peroneal tendons in passive stabilisation of the ankle joint: an in vitro study. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2273-2

[99] Modified Arthroscopic Brostrom Procedure With Bone Tunnels. Arthroscopy Techniques. 2016. DOI: 10.1016/j.eats.2016.03.003

[100] The role of the medial ligaments in lateral stabilization of the ankle joint: an in vitro study. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2708-4

[101] Medial Ankle Stability Evaluation With Dynamic Ultrasound: Establishing Natural Variations in the Healthy Cohort. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-20-00597

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

[104] Peroneal electromechanical delay and fatigue in patients with chronic ankle instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4243-6

[105] Anatomic Lateral Ligament Reconstruction in the Ankle. The American Journal of Sports Medicine. 2012. DOI: 10.1177/0363546512455397

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

[107] 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

[110] Tibiocalcaneal Augmentation of Deltoid Ligament Repair Improves Ankle Stability: A Robotic Investigation of Ankle Biomechanics. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465251352739

[111] Foot and Shank Coordination During Walking in Copers Compared With Patients With Chronic Ankle Instability and Controls. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221139482

[113] Imaging diagnosis for chronic lateral ankle ligament injury: a systemic review with meta-analysis. Journal of Orthopaedic Surgery and Research. 2018. DOI: 10.1186/s13018-018-0811-4

[115] Three-dimensional analysis of anterior talofibular ligament strain patterns during cadaveric ankle motion using a miniaturized ligament performance probe. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04058-2

[117] Paper #50: In Vivo Kinematics of the Ankle During Gait Following Reconstruction for Chronic Ankle Instability. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2013.07.054

[118] Biomechanics of Ankle Ligament Reconstruction: A Cadaveric Study to Compare Stability of Reconstruction Techniques Using 1 or 2 Fibular Tunnels. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120959284

[122] Bone Anchors or Interference Screws?. The American Journal of Sports Medicine. 2004. DOI: 10.1177/0363546504265051

[123] Ligamentoplasty using the peroneus brevis in the treatment of chronic instabilities of the ankle. Long-term review. Orthopaedics & Traumatology: Surgery & Research. 2014. DOI: 10.1016/j.otsr.2013.12.003

[125] 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

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

[128] Dynamic postural stability indices in athletes: a case-control study on chronic ankle instability during multi-directional landing assessments. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09307-2

[129] Deltoid and Syndesmotic Ligaments, Part 2. The Value of Ligament Repair and Augmentation in Restoring Biomechanical Rotational Ankle Stability. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465251361148

[130] Single-leg drop landing movement strategies in participants with chronic ankle instability compared with lateral ankle sprain ‘copers’. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3852-9

[133] Novel anatomical reconstruction of distal tibiofibular ligaments restores syndesmotic biomechanics. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4485-y

[135] Campbell S Operative Orthopaedics 4 Volume Set. REPAIR OF ACUTE RUPTURE OF LATERAL LIGAMENTS > MEDIAL REPAIR OF CHRONIC INSTABILITY.

[137] Does the contralateral healthy ankle of patient with ipsilateral mechanical lateral ankle laxity show greater lateral ankle laxity? Evaluation of the anterior talofibular ligament by stress ultrasonography. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05838-0

[138] Functional Outcomes of Immediate Weightbearing After Arthroscopic Lateral Ankle Ligament Repair: A Prospective Randomized Single-Center Trial. The American Journal of Sports Medicine. 2024. DOI: 10.1177/03635465241289946

[144] Paper 61. Immediate Weight Bearing after Modified-Brostrom Reconstruction: A Retrospective Review of an Accelerated Rehab Protocol. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00318

[145] Lateral Ankle Stabilization After Distal Fibular Resection Using a Novel Approach: A Surgical Technique. Clinical Orthopaedics & Related Research. 2014. DOI: 10.1007/s11999-013-3408-6

[146] 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

[147] The Surgical Treatment of Injuries of the Fibular Collateral Ligaments of the Ankle. The Journal of Bone & Joint Surgery. 1961. DOI: 10.2106/00004623-196143020-00011

[148] Ligament Augmentation Reconstruction System (LARS) for Ankle Lateral Ligament Reconstruction in Higher-Risk Patients: A 5-Year Prospective Cohort Study. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221093968

[150] The lateral fibulotalocalcaneal ligament complex: an ankle stabilizing isometric structure. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5188-8

[151] INJURIES OF THE LATERAL LIGAMENTS OF THE ANKLE. The Journal of Bone & Joint Surgery. 1949. DOI: 10.2106/00004623-194931020-00013

[152] 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

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

[158] 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

[161] Chronic Ankle Instability (Medial and Lateral). Clinics in Sports Medicine. 2015. DOI: 10.1016/j.csm.2015.06.004

[162] Transformer‐Based Multilabel Deep Learning Model Is Efficient for Detecting Ankle Lateral and Medial Ligament Injuries on Magnetic Resonance Imaging and Improving Clinicians’ Diagnostic Accuracy for Rotational Chronic Ankle Instability. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.05.027

[163] 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

[165] Magnetic Resonance Imaging of the Foot and Ankle. Journal of the American Academy of Orthopaedic Surgeons. 2001. DOI: 10.5435/00124635-200105000-00005

[166] Reliability and validity of different ankle MRI scanning planes for the anterior talofibular ligament injury diagnosis: a cadaveric study. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1102-4

[169] Avulsion fracture is associated with more pain after anatomic repair procedure for ATFL injury at the talar side. Knee Surgery, Sports Traumatology, Arthroscopy. 2023. DOI: 10.1007/s00167-023-07658-8

[170] Reconstruction of the lateral ligament of the ankle. Injury. 1975. DOI: 10.1016/0020-1383(75)90065-0

[171] 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

[172] Combined anterior and posterior ankle impingement syndrome with nonunion of Cedell fracture in a 58-year-old female: a case report. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03584-9

[174] Individual fascicles of the ankle lateral ligaments and the lateral fibulotalocalcaneal ligament complex can be identified on 3D volumetric MRI. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07275-x

[175] Radiographic Identification of the Syndesmotic Structures of the Ankle. Orthopaedic Journal of Sports Medicine. 2015. DOI: 10.1177/2325967115s00041

[176] The feasibility of point-of-care ankle ultrasound examination in patients with recurrent ankle sprain and chronic ankle instability: Comparison with magnetic resonance imaging. Injury. 2017. DOI: 10.1016/j.injury.2017.07.015

[181] Anatomic Reconstruction With a Semitendinosus Allograft for Chronic Lateral Ankle Instability. The American Journal of Sports Medicine. 2015. DOI: 10.1177/0363546515593942

[184] CORR Insights®: Apoptosis Occurs in the Anterior Talofibular Ligament of Patients With Chronic Lateral Ankle Instability: An In Vitro Study. Clinical Orthopaedics & Related Research. 2022. DOI: 10.1097/corr.0000000000002404

[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] Strength of Suture Anchor Versus Transosseous Tunnel in Anatomic Reconstruction of the Ankle Lateral Ligaments: A Biomechanical Study. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2013.08.015

[189] 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

[190] Chronic ankle instability has no correlation with the number of ruptured ligaments in severe anterolateral sprain: a systematic review and meta‐analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06610-y

[196] Reoperation rates following ankle ligament procedures performed with and without concomitant arthroscopic procedures. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4207-x

[198] Risk Factors for the Recurrence of Instability after Lateral Ankle Ligament Repair for Chronic Lateral Ankle Instability: A Systematic Review. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100420

[199] Percutaneous Calcaneal Osteotomy Combined With Arthroscopic Lateral Ankle Ligament Reconstruction for Chronic Ankle Instability With Hindfoot Varus. Arthroscopy Techniques. 2024. DOI: 10.1016/j.eats.2024.102989