Surgical Procedures for Chronic Lateral Ankle Instability

Youichi Yasui, MD; Yoshiharu Shimozono, MD; John G. Kennedy, MD, MCh, MMSc, FFSEM, FRCS (Orth)


J Am Acad Orthop Surg. 2018;26(7):223-230. 

In This Article

Abstract and Introduction


Surgical procedures for managing chronic lateral ankle instability include anatomic direct repair, anatomic reconstruction with an autograft or allograft, and arthroscopic repair. Open direct repair is commonly used for patients with sufficient ligament quality. Reconstruction incorporating either an autograft or an allograft is another promising option in the short term, although the longevity of this procedure remains unclear. Use of an allograft avoids donor site morbidity, but it comes with inherent risks. Arthroscopic repair of chronic lateral ankle instability can provide good to excellent short- and long-term clinical outcomes, but the evidence supporting this technique is limited. Deterioration of the ankle joint after surgery is also a concern. Studies are needed on not only treating ligament insufficiency but also on reducing the risk of ankle joint deterioration.


Chronic lateral ankle instability (CLAI) is a common source of ankle dysfunction.[1] This pathology may involve mechanical and/or functional instability. The anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) are the major static lateral ligamentous stabilizers.[2] The ATFL is the primary constraint to inversion stress in plantar flexion. Most patients experiencing mechanical instability have either an ATFL injury alone or combined ATFL and CFL injuries.[2]

Nonsurgical treatment is often successful in patients with CLAI. When symptoms persist despite an adequate trial of nonsurgical management, surgical treatment aimed at restoring ankle stability is typically indicated. A variety of surgical techniques has been described, including anatomic direct repair with or without local tissue augmentation, anatomic ligament reconstruction using either an autograft or an allograft, and arthroscopic repair. Anatomic direct repair with or without inferior extensor retinaculum (IER) augmentation remains the first-line surgical treatment of CLAI, except in the setting of malalignment or in a patient with global laxity or in whom robust soft tissue is absent. Nevertheless, a 2011 Cochrane review concluded that clinical evidence is insufficient to determine the optimal surgical strategy for this instability.[3]

An up-to-date assessment of the evidence regarding CLAI indicates that short- and long-term outcomes and complication rates vary depending on the surgical procedure. Additional studies, including comparative trials of these techniques, are needed.