Aims. This cross-sectional study aimed to investigate the in vivo ankle kinetic alterations in patients with concomitant chronic ankle instability (CAI) and osteochondral lesion of the talus (OLT), which may offer opportunities for clinician intervention in treatment and rehabilitation. Methods. A total of 16 subjects with CAI (eight without OLT and eight with OLT) and eight healthy subjects underwent gait analysis in a stair descent setting. Inverse dynamic analysis was applied to ground reaction forces and marker trajectories using the AnyBody Modeling System. One-dimensional statistical parametric mapping was performed to compare ankle joint reaction force and joint moment curve among groups. Results. The patients with OLT showed significantly increased dorsiflexion moment in the ankle joint compared with healthy subjects during 38.2% to 40.9% of the gait cycle, and increased eversion moment in the ankle joint compared with patients without OLT during 25.5% to 27.6% of the gait cycle. Compared with healthy subjects, the patients with OLT showed increased anterior force during 42% to 43% of the gait cycle, and maximal medial force (p = 0.005, ηp2 = 0.399). Conclusion. The patients with concomitant CAI and OLT exhibit increased dorsiflexion and eversion moment, as well as increased anterior and medial ankle joint reaction force during stair descent, compared with patients with CAI but without OLT and healthy subjects, respectively. Thus, a rehabilitative regimen targeting excessive ankle dorsiflexion and eversion moment may help to reduce ankle joint loading. Cite this article: Bone Joint Res 2024;13(12):716–724

Introduction. Chronic ankle instability is a common condition that can be effectively treated with arthroscopic lateral ankle ligament reconstruction to restore ankle stability and function. The aim of this study was to assess the functional outcomes of arthroscopic lateral ligament reconstruction using the MOXFQ, VAS, and EQ5D patient-reported outcome measures (PROMs). Methods. This prospective series included 38 patients who underwent arthroscopic lateral ligament reconstruction for chronic ankle instability between December 2019 and April 2022. All patients completed the MOXFQ, VAS, and EQ5D PROMs preoperatively, as well as at6, and 12 months postoperatively. The MOXFQ is a disease-specific PROM that assesses foot and ankle function, while the VAS measures pain and the EQ5D evaluates health-related quality of life. Results. At the 12-month follow-up, the mean MOXFQ Index score had improved significantly from 53.3 ± 23.1 preoperatively to 16.0 ±21.1 (p < 0.001). Similarly, the mean VAS score had improved from 36.2 ± 22.4 preoperatively to 14.7 ± 15.0 (p < 0.001), and the meanEQ5D score had improved from 0.55 ± 0.26 preoperatively to 0.87 ± 0.12 (p < 0.001). No major complications were observed. Conclusion. Arthroscopic lateral ligament reconstruction is an effective treatment for chronic ankle instability, with significant improvements in clinical and health-related quality of life outcomes

Purpose: Chronic ankle instability is generally related to lateral laxity of the tibiotalar joint. Stress x-rays may however be negative. Varus of the hindfoot is another possibility. In such cases, it would be logical to propose Dwyer valgus osteotomy of the calcaneum. The objective of this work was to review patients who underwent Dwyer osteotomy from 1992 to 2000. Material and methods: The series included fifteen patients, nine men and six women, who complained of chronic ankle instability with no evidence of laxity. All presented a varus hindfoot (mean 5°, range 3–10°). Thirteen patients practiced sports, including eight at the competition level. Sixty percent had experienced instability accidents during sports activities. Associated lesions were fissures of the fibular tendons (n=2), osteochondral lesion of the talar dome (n=1), Haglund disease (n=1) and stage II pes cavus (n=2). Lateral closed Dwyer osteotomy was performed in all cases, generally with fixed with two screws in a 2-hole 1/3 plate. Associated procedures were: lateral ligamentoplasty (n=1), osteotomy to raise M1 (n=2), regularisation of an osteochondral lesion of the talar dome (n=1), Zadek osteotomy (n=1) and anterior arthrolysis (n=1). The same surgeon reviewed the patients clinically and radiologically, independent of the operator. Results: Mean follow-up was 3.5 years (range 1–9, SD 2.5). There were no complications except one case of cutaneous necrosis in the patient who had simultaneous osteotomy and ligamentoplasty. Instability resolved in all patients. Ten patients experienced minor episodic pain (50% during sports activities). Eleven patients (70%) resumed their sports activities within eight months (3–36) and 33% at their former level. The mean Kitaoka score was 92 (85–100) and 80% of the patients were satisfied or very satisfied. Conclusion: Dwyer osteotomy provides quite satisfactory results for patients with chronic ankle instability without evidence of laxity and hindfoot varus. When a complementary ligamentoplasty appears to be necessary, it is preferable to wait for a second operation in order to avoid the risk of cutaneous necrosis

Aims: Hindfoot deformity in varus position is an aetiology of chronic ankle instability without laxity. In this condition, a Dwyer osteotomy has to be performed. Methods: Between 1992 and 2000, 15 patients have been operated on, with this technique. The mean varus deformity was of 5û (3û to 10û).13 patients had sporting activities, 8 of them in competition. Instability during sporting activity were present in 60% of cases. Associated lesions were reported in 6 cases. A Dwyer procedure using a 1/3 tube plate þxed with two screws were performed in all cases. Associated procedures were performed at the same time as such as a lateral ligamentoplasty or a þrst metatarsal osteotomy. All patients were reviewed clinically and radiologically using AOFAS score. Results: The mean follow-up was of 3.5 years (1 to 9 years). The only one complication reported was a skin necrosis, treated by a cutaneous ßap in a patient operated on with Dwyer and ligamentoplasty in the same procedure. No ankle instability was reported. Mild pain was reported in 10 patients and 50% of them only for sporting activities.11 patients returned to sporting activity and 33% of them at the same level. The mean Kita-oka score was of 92 (85 to 100). The patients were satisþed and very satisþed in 80 of cases. Conclusions: Dwyer lateral closing wedge calcaneal osteotomy is successful for the treatment of chronic ankle instability without laxity and with varus hindfoot deformity. When laxity is associated with varus deformity an operative procedure in two steps is necessary to avoid wound complication. Dwyer osteotomy has to be performed þrst

Introduction: Ankle sprains are among the most common injuries in sports and recreational activities. 10 to 40% of the acute ankle sprains lead to chronic ankle instability (CAI), which can be divided into its mechanical and its functional division. The clinical-orthopaedic diagnosis of mechanical ankle instability (MAI) has been well established, whereas the etiology of the functional ankle instability (FAI) is still not objectively allocatable. The aim of this study was to identify neuromuscular patterns in lower leg muscles to objectively describe the FAI. Methods: 15 patients suffering from unilateral CAI (mean age, 35.5 years) since 2.4 years (1–9 years) were examined. The patients were evaluated etiologically and clinically (VAS pain score, AOFAS Ankle Score, calf circumference, and SF-36). Electromyographic (EMG) measurements of surface EMG with determination of mean EMG frequency and intensity by wavelet transformation were taken synchronously with dynamic stabilometry measurements. Four lower leg muscles were detected: tibialis anterior (TA), gastrocnemius medialis (GM), soleus (SO), and peroneus longus (PL) muscle. 15 healthy subjects were tested identically. Results: Patients showed higher stability indices, higher VAS score, and lower AOFAS Ankle Score. The mean EMG frequency was significantly lower for the PL (pathologic leg, 138.3 Hz; normal leg, 158.3 Hz, p< 0.001). Lower mean EMG intensity was found in the pathologic PL and GM. The mean EMG frequency of the TA was lower in the patient group, its intensity higher. Discusssion and conclusion: Patients suffering CAI demonstrate weakened stability and impaired life quality. Neuromuscular patterns of the GM, PL and TA lead evidently to an objective etiology of the functional ankle instability. EMG patterns of four lower leg muscles indicate chronic changes in muscle morphology, such as degradation of type-II muscle fibres or modified velocity of motor unit action potentials. Accurate prevention and rehabilitation may compensate a MAI with a sufficient functional potential of lower leg muscles. This may also avoid operative treatment of MAI. The present study evidences the etiology of the FAI with objective parameters and indicates chronic changes in muscle morphology within CAI-Patients

Introduction: Ankle inversion injuries are common, with an incidence of 1 per day per 10,000 of the population. Chronic instability is a frequent sequela, and has been estimated to occur after approximately 10 to 20% patients, regardless of the type of initial treatment. Magnetic Resonance Imaging (MRI) has become a routine diagnostic tool in investigating knee injuries, but little has been published concerning ankle injuries and ankle instability. Aim: To compare the efficacy of conventional magnetic resonance (MR) imaging and stress radiography in the detection of lateral collateral ligament abnormalities in patients with chronic ankle instability. Materials and Methods: All patients presenting to the senior author’s OPD with clinical impression of ankle instability were investigated prospectively using MRI and stress x-rays (Telos). These films were officially reported and then, these reports were subsequently reviewed post-anatomical reconstruction. Results: Over a two-year period, 18 patients underwent anatomical reconstruction using the modified Brostrom technique. MRI identified a tear of the anterior talofibular (AFT) ligament in 12 (66%) patients, and the calcaneofibular (CF) ligament was torn in 9 (50%) patients. Stress radiography identified instability of 14 of the 18 (77%) patients. Stress radiography identified instability of 14 of the 18 (77%) patients. Surgical exploration revealed either attenuation or rupture of either the AFT and/or CF ligaments in all 18 patients. MRI demonstrated concomitant injuries to the ankle and subtalar joints, including peroneal tenosynovitis (76%), anterolateral impingement syndrome (66%) and attenuated peroneal retinaculum (55%). Conclusion: Ankle instability may be more reliably demonstrated using stress x-rays than MRI: however, lowfield MRI is a very useful diagnostic tool in the study of concomitant ankle injuries and we would suggest that both modalities be considered, especially if surgical intervention is anticipated

Purpose: Ankle sprains are among the most common injuries in sports and recreational activities. 10 to 40% of the acute ankle sprains lead to chronic ankle instability (CAI), which can be divided into its mechanical and its functional division. The clinical-orthopaedic diagnosis of mechanical ankle instability (MAI) has been well established, whereas the etiology of the functional ankle instability (FAI) is still not objectively allocatable. The aim of this study was to identify neuromuscular patterns in lower leg muscles to objectively describe the FAI. Method: 15 patients suffering from unilateral CAI (mean age, 35.5 years) since 2.4 years (1–9 years) were examined. The patients were evaluated etiologically and clinically (VAS pain score, AOFAS Ankle Score, calf circumference, and SF-36). Electromyographic (EMG) measurements of surface EMG with determination of mean EMG frequency and intensity by wavelet transformation were taken synchronously with dynamic stabilometry measurements. Four lower leg muscles were detected: tibialis anterior (TA), gastrocnemius medialis (GM), soleus (SO), and peroneus longus (PL) muscle. 15 healthy subjects were tested identically. Results: Patients showed higher stability indices, higher VAS score, and lower AOFAS Ankle Score. The mean EMG frequency was significantly lower for the PL (pathologic leg, 138.3 Hz; normal leg, 158.3 Hz, p< 0.001). Lower mean EMG intensity was found in the pathologic PL and GM. The mean EMG frequency of the TA was lower in the patient group, its intensity higher. Conclusion: Patients suffering CAI demonstrate weakened stability and impaired life quality. Neuromuscular patterns of the GM, PL and TA lead evidently to an objective etiology of the functional ankle instability. EMG patterns of four lower leg muscles indicate chronic changes in muscle morphology, such as degradation of type-II muscle fibres or modified velocity of motor unit action potentials. Accurate prevention and rehabilitation may compensate a MAI with a sufficient functional potential of lower leg muscles. This may also avoid operative treatment of MAI. The present study evidences the etiology of the FAI with objective parameters and indicates chronic changes in muscle morphology within CAI-Patients

Introduction and purpose: Numerous surgical procedures have been developed for the treatment of chronic ankle instability, which can be broken down into two: tenodesis of the peroneus brevis and ligament capsuloplasty. We assess the indications for these procedures, discuss their advantages and disadvantages based on a comparative review, and describe an algorithm in the treatment of this pathology. Materials and methods: We reviewed 21 patients who underwent surgery from 1997 to 2001. In 10 of the patients the operation consisted of a Castaing II procedure with tenodesis of the peroneus brevis, and in 11 a Larsson procedure was performed as a ligament capsuloplasty. The ankle was evaluated using the AOFAS scale. Results: The age difference between the two groups, which was 40 for those undergoing the Castaing II procedure and 28 for the Larsson technique. The mean AOFAS score was 80% (min. 70%, max. 95%) for the Castaing II procedure and 86% (min. 71%, max. 97%) for the Larsson technique. Conclusions: The use of tenodesis with the peroneus brevis is indicated for severe ankle instability, failed anatomical repairs and in patients with connective tissue pathology. A capsuloplasty that attempts to reconstruct the lateral ligaments of the ankle as anatomically as possible is indicated for mild-to-moderate chronic instability in young patients

We describe the surgical treatment of 13 cases of chronic lateral ankle instability and concomitant anterior tibiotalor bony impingement of the ankle in servicemen, professional and recreational athletes. All patients had symptoms and signs of lateral instability and a painful block to dorsiflexion. Two patients presented with recurrence of impingement after a previous debridement alone without an ankle stabilisation. The anterior osteophytes were debrided arthroscopically and a Brostrom-Gould open stabilisation performed. After a mean follow up period of 12 months (range 4–23 months), all 13 patients had mechanically and functionally stable ankles. The mean improvement in range of dorsiflexion was 9 degrees and all but 1 had improvement with respect to a subjective and functional outcome assessment. There have been no recurrences of impingement to date. Our results suggest that ankle stabilisation performed in conjunction with debridement of osteophytes may reduce the recurrence of exostoses as well as improving the outcome

Objectives

To evaluate the applicability of MRI for the quantitative assessment of anterior talofibular ligaments (ATFLs) in symptomatic chronic ankle instability (CAI).

Introduction

Lateral ligament reconstruction of the ankle for chronic symptomatic mechanical instability is a relatively common procedure for Foot and Ankle surgeons to undertake. The following method has been undertaken by the Senior Author for the past ten years.

Materials and Methods

We studied 26 patients (26 feet). The average age was 32 years with 16 males and 10 females. Duration of follow up was from 11 months to 11 years.

Preoperative Investigations

Functional instability and alternative diagnoses such as tendonopathy and previously unrecognised fractures were excluded, sometimes by extensive investigations. All patients undergoing surgery had a period of conservative treatment which had failed. Stress radiographs confirmed instability in two planes and was either undertaken preoperatively or just prior to surgery under anaesthesia.

Surgical Technique

Through a small oblique lateral incision, the lateral capsule, ligaments and periosteum were advanced over the tip of the fibula in a proximal and posterior direction and re-anchored tightly to the bone, usually with Mitek (titanium) bone anchors.

Postoperative Management

The patients were casted for six weeks whilst weight bearing, followed by six weeks of physiotherapy.

Results

The success rate was over 85%. The complications were scar tenderness, recurrent instability and ankle spurring. There were no complications caused by the metallic anchors.

Conclusion

This procedure has a comparable success rate with similar anatomical ligament reconstructive procedures and can be recommended.

Mechanical ankle instability is elicited through examination and imaging. A subset of patients however report “functional” instability ie/ instability without objective radiological evidence. Little research compares operative outcomes between these groups. We hypothesised patients with “mechanical instability” were more likely to benefit from operative intervention than those with “functional instability”.

This was a single centre, retrospective case note review of prospectively collected data. Inclusion criteria: over six months of symptoms, failed conservative management, surgical stabilisation between 2016–2018. Data collected: demographics, operative procedure, preoperative and postoperative PROMs.

Nineteen patients were included. All had preoperative MRIs determining ligamentous involvement. Nine had radiological evidence of instability, eight had negative radiographs. Two were excluded due to no intraoperative radiographs.

There was no statistical difference in preoperative MOxFQ scores between the groups (p=0.2039). Preoperative EQ5D-TTO scores were statistically different (mean mechanical 0.58 vs functional 0.26, p=0.0162) but not EQ5D-VAS scores (mean mechanical 77 vs functional 53, p=0.0806).

Mechanical group's preoperative, 26 and 52 week scores respectively: Mean MOxFQ= 57.88, 22.13, 18.5. Mean EQ5D-TTO= 0.58, 0.78, 0.84. EQ5D-VAS= 77, 82, 82.5.

Functional group's preoperative, 26 and 52 week scores respectively: Mean MOxFQ= 71.87, 37.75, 23. Mean EQ5D-TTO 0.26, 0.63, 0.76. EQ5D-VAS 53, 80, 88.

This trend of improvement in PROMs was not reflected in patient satisfaction scores. 75% of respondents in the functional group reported dissatisfaction at 26 weeks versus no dissatisfaction in the mechanical group. We should consider counselling patients accordingly when offering surgery.

Aims: Lateral ligament complex injuries are a common cause of chronic ankle instability. It has been found that functional and mechanical instability of the ankle joint can respond to arthroscopic debridement of the ankle alone and that not all structurally unstable joints require stabilisation. The aim of this study was to find out the role of EUA & Arthroscopy in the management of these problems. Methods: We retrospectively studied 43 patients with chronic lateral ankle instability who had failed to respond to a functional rehabilitation programme. All patients underwent an examination under anaesthesia with stress views to determine instability proceeded by arthroscopic examination of the ankle. Results: Intra-articular bony lesion was seen in 41.8% of cases. 79.1% had fibrosis in the anterolateral gutter, 27.9% had osteochondral defect, 30.2% had osteophytes causing impingement and 9.3% had loose bodies. Structural instability was confirmed in 53.4% and functional instability in 46.6%. Arthroscopy demonstrated attenuation of the Anterior Talofibular ligament in 14%. Following arthroscopic debridement lateral reconstruction was required in only 14(32.5%). 23 patients (53.4%) went on to improve after arthroscopy alone and did not need lateral reconstruction. Conclusion: Arthroscopic assessment and treatment of intraarticular lesion in patients with chronic ankle instability can result in a stable ankle that does not necessitate a lateral ligament complex reconstruction

Introduction and Aims: Lateral ligament complex injuries are a common cause of chronic ankle instability. It has been found that functional and mechanical instability of the ankle joint can respond to arthroscopic debridement of the ankle alone and that not all the structurally unstable joints require stabilisation. Method: We retrospectively studied 43 patients with chronic lateral ankle instability who had failed to respond to a functional rehabilitation program. All patients underwent an examination under anaesthesia with or without stress views to determine instability and this was preceded by arthroscopic examination of the ankle. Results: Intra-articular lesion was seen in 41.8% of cases. 79.1% had fibrosis in the anterolateral gutter, 27.9% had osteochondral defect, 30.2% had osteophytes causing impingement and 9.3% had loose bodies. Structural instability was confirmed in 53.4% and functional instability in 46.6%. Arthroscopy demonstrated attenuation of the Anterior Talofibular ligament in 14%. Following arthroscopic debridement lateral reconstruction was required in only 14 (32.5%). Twenty-three patients (53.4%) went on to improve after arthroscopy alone and did not need lateral reconstruction. Three patients (6.9%) were lost to follow-up and three (6.9%) needed further procedures. Conclusion: Arthroscopic assessment and treatment of intra-articular lesion in patients with chronic ankle instability can result in a stable ankle that does not necessitate a lateral ligament complex reconstruction

Aims Lateral ligament complex injuries are a common cause of chronic ankle instability. It has been found that functional and mechanical instability of the ankle joint can respond to arthroscopic debridement of the ankle alone and that not all structurally unstable joints require stabilisation. The aim of this study was to find out the role of examination under anaesthesia (EUA) and arthroscopy in the management of these problems. Method We retrospectively studied 43 patients with chronic lateral ankle instability who had failed to respond to a functional rehabilitation programme. All patients underwent an EUA with stress views to determine instability, proceeded by arthroscopic examination of the ankle. Results Intra-articular bony lesion was seen in 41.8% of cases. Fibrosis in the anterolateral gutter was found in 79.1%, 27.9% had osteochondral defect, 30.2% had osteophytes causing impingement and 9.3% had loose bodies. Structural instability was confirmed in 53.4% and functional instability in 46.6%. Arthroscopy demonstrated attenuation of the anterior talofibular ligament in 14%. Following arthroscopic debridement lateral reconstruction was required in only 14 (32.5%). Twenty-three patients (53.4%) went on to improve after arthroscopy alone and did not need lateral reconstruction. Three patients (6.9%) needed supplementary procedures for other associated problems. Conclusion Arthroscopic assessment and treatment of intraarticular lesion in patients with chronic ankle instability can result in a stable ankle that does not necessitate a lateral ligament complex reconstruction

The present study sought to assess the clinical and radiological results and long-term joint impact of different techniques of lateral ankle ligament reconstruction.

AIM: The purpose of this retrospective study was to assess the results of a novel surgical technique for chronic lateral ankle instability using dynamic extensor digitorum brevis (EDB) muscle transfer. METHODS: 15 patients underwent dynamic EDB muscle transfer for symptomatic chronic lateral ankle instability. All patients were quite fit and physically very active. 9 male and 6 female patients, mean age 27 (range, 22–32) were operated by single surgeon (ALP) between March 2003 and August 2005. All patients had standard procedure involving proximal transfer of the origin of EDB muscle whilst preserving its neuro-vascular pedicle. All patients went through a standard post-operative physiotherapy protocol including pro-prioceptive training. Mean follow-up was 24 months (range, 12–36 months). The mean functional Karlsson scores improved from 26.5 before surgery to 86.5 at 12 months after surgery. At follow-up, all patients had normal range of ankle movements and were functionally stable. All patients regained their pre-injury activity level at 12 months after surgery. There were no early or late complications in our series. DISCUSSION: Ankle sprains are the most common injuries sustained during sports and physical exercise. Treatment is usually conservative because most of these injuries heal without consequence. However, symptomatic chronic lateral ankle instability is a difficult problem to treat and several surgical techniques have been described. EDB muscle not only acts as a dynamic substitute for the deficient ligament but also overcomes the problem of over-tightening of the ligament leading to restricted supination. CONCLUSION: Dynamic EDB muscle transfer is a safe, clinically effective and reliable surgical option for symptomatic chronic lateral ankle instability

The ‘gold standard’ for treatment of chronic ankle instability is Brostrom-Gould procedure, which is an ‘open’ surgery. Most authors recommend this type of operation even after an arthroscopic inspection of the joint. The arthroscopic methods, including thermal shrinkage, propose in the past didn’t received a widely spread support. We present a method of arthroscopic lateral ligament ‘repair’ with an anchor placed in the fibula. We used this technique on 31 consecutive patients (28 were available for follow-up). 21 patients were victims of work or traffic accidents and 3 had sport-related lesions. The patients were evaluated after a 24,5 month follow-up. The average post-op AOFAS score was 85,3 and average satisfaction was 3,77 (1 to 5). We had two ‘relapses’ (another sprain without instability on the stress XR). On 3 patients we had some wound healing problems and we had 3 lesions of the superficial peroneal nerve, one of these is persistent. One patient developed a deep vein thrombosis post operatively. With this method, we achieved good results with relatively few complications, even more considering that most of the patients were work-compensation cases. It’s a simple procedure, less ‘aggressive’ then the traditional one’s, producing an anatomical and functional repair of the lateral ligament

Purpose of the study: The objectives of this work were to assess the stability of outcome achieved after Duquennoy procedure to tighten the lateral capsule-ligament structures of the ankle joint. To do this, we reviewed the same series of patients at 3 and 25 years follow-up to analyse the very long-term stability, laxity, and stiffness of the ankle joint and any osteoarthritic degradation.

Material and methods: From 1975 to 1986, we performed 75 Duquennoy procedures on the lateral capsule and ligament structures of the ankle joint. At mean 25 years follow-up (2007) we were able to review 28 ankles (27 patients) with the same method as applied in 1980 (3 years follow-up). The function outcome was assessed with the Good, Karlsson, Duquennoy and Tegner scores. Clinically, other than joint range of motion, were noted varus laxity or anterior drawer. Static x-rays were obtained to search for signs of osteoarthritis and stress images to measure talocrural laxity, in comparison with the preoperative figures and the 1980 data.

Results: There were two early technique failures (one persistent talocrural instability, one subtalar instability). Good and Karlsson scores were good or excellent in 92% of cases. Patients were very satisfied with the operation and the VAS was 8.9/10. Pain and occasional instability were reported by 27% of patients. There was no talocrural no subtalar stiffness at last follow-up. Radiographic laxity declined significantly between the preoperative value and the last review. Only one patient presented a narrow talocrural space (less than 50% narrowing). Eight patients had osteophytes whose presence was not correlated with poor functional outcome. These osteophytes were also present on the controlateral side. Importantly, there was no significant difference in the mean function scores between 3 and 25 years follow-up (Duquennoy score). Similarly joint range of motion and radiographic laxity remained stable over time.

Discussion: The Duquennoy procedure to tighten the lateral capsule and ligament structures is a simple technique with rare complications which provides excellent results both in terms of ligament stability and in terms of preservation from degenerative osteoarthritis. These results remain stable over time. Conversely, the technique has no action on the subtalar joint and should not be proposed as treatment for associated subtalar laxity, if diagnosed.

Chronic lateral ankle instability (CLAI) is treated operatively, whereas acute ligament injury is usually treated nonoperatively. Such treatments have been widely validated. Apoptosis is known to cause ligament degeneration; however, few reports have focused on the possible role of apoptosis in degeneration of ruptured lateral ankle ligaments. The aim of our study is to elucidate the apoptosis that occurs within anterior talofibular ligament (ATFL) to further validate current CLAI treatments by adducing molecular and cellular evidence. Between March 2019 and February 2021, 50 patients were prospectively enrolled in this study. Ruptured ATFL tissues were collected from 21 CLAI patients (group C) and 17 acute ankle fracture patients (group A). Apoptotic cells were counted using the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling (TUNEL) assay. Western blotting for caspases 3, 7, 8, and 9 and cytochrome c, was performed to explore intrinsic and extrinsic apoptotic pathways. Immunohistochemistry was used to detect caspases 3, 7, 8, and 9 and cytochrome c, in ligament vessel endothelial cells. More apoptotic cells were observed in group C than group A in TUNEL assay. Western blotting revealed that the apoptotic activities of group C ligaments were significantly higher than those of group A (all p < 0.001). Immunohistochemistry revealed increased expression of caspases 3, 7, 8, and 9, and cytochrome c, in group C compared to group A. The ATFL apoptotic activities of CLAI patients were significantly higher than those of acute ankle fracture patients, as revealed biochemically and histologically. Our data further validate current CLAI treatments from a molecular and cellular perspective. Efforts should be made to reverse or prevent ATFL apoptosis in CLAI patients