Lateral Ligament Reconstruction

Indication. Symptomatic chronic lateral ankle instability (CLAI) — recurrent giving way, pain and functional limitation after at least one significant inversion sprain — that has failed a structured conservative programme of proprioceptive training, peroneal strengthening and activity modification (with bracing or taping) for a minimum of 3 months (extended to 6 months in low-demand patients). The decision to operate rests on three pillars, all of which must be present:

Distinguish mechanical from functional instability first. This is the single most important pre-operative decision — surgery helps mechanical instability and does not help (and may harm) functional instability.

Look for and plan to address concomitant pathology — present in 40–70% of chronic cases and a cause of persistent symptoms if missed: - Osteochondral lesion of the talus (around 35%) — requires concurrent arthroscopic debridement/fixation.

• Peroneal tendon pathology (around 25%) — tears or subluxation.
• Sinus tarsi syndrome (around 20%) and anterior ankle impingement from osteophytes.
• Subtalar instability, which may need separate stabilisation.
• Hindfoot varus — the critical alignment issue (see below).

Contraindications. Absolute: active infection, severe peripheral vascular disease, Charcot arthropathy. Relative: uncorrected hindfoot varus (correct first), generalised ligamentous laxity (Beighton greater than 6 — favour non-anatomic reconstruction), a poor soft-tissue envelope, and unrealistic patient expectations. Consent specifically for superficial peroneal nerve injury/numbness or a painful neuroma (5–10%), wound problems or infection (3–5%), ankle or subtalar stiffness (10–15% after anatomic repair), recurrent instability (5–15%), and incomplete relief if concomitant pathology is not addressed. Setup. Supine with a bump under the ipsilateral hip, thigh tourniquet, foot over the end of the table for access. Loupe magnification helps nerve and ligament identification.

The goal is to restore the normal lateral ligament complex anatomically — re-tension the attenuated ATFL and CFL, reinforce the repair with the inferior extensor retinaculum (Gould), and protect the superficial peroneal nerve throughout. The anterolateral exposure is laid out as the first steps below (and in depth on the anterolateral approach to the ankle page). Non-anatomic tenodesis is reserved for salvage and is described as the final operative steps.

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Rehabilitation | Phase | Timing | Immobilisation | Activity & therapy | |-------|--------|----------------|--------------------| | 1 — Protection | 0–2 weeks | Posterior splint or CAM boot, non-weight-bearing | Toe wiggling, muscle pumps; no inversion, no weight-bearing; sutures out at 10–14 days | | 2 — Early motion | 2–6 weeks | CAM boot, progress to 50% weight-bearing by week 6 | Active ankle pumps, gentle dorsiflexion/plantarflexion ROM (no inversion); therapy from week 3–4 | | 3 — Strengthening | 6–12 weeks | Lace-up brace (e.g. ASO), full weight-bearing | Progressive resistance (theraband), proprioception/balance; elliptical, bike, swimming | | 4 — Return to sport | 3–6 months | Ankle brace for sport for 12 months | Straight-line jogging, cutting drills, sport-specific; full strength and negative functional tests to return | Most patients return to sedentary work at 6–8 weeks and manual labour at 10–12 weeks. Around 85–95% return to their pre-injury activity level. Proprioceptive training is essential to prevent recurrence, and an external brace is recommended for sport for 12 months.

Complications

Epidemiology. Lateral ankle sprains are among the most common musculoskeletal injuries worldwide and are especially frequent in court and field sports (basketball, netball, football codes, volleyball). The ATFL is involved in the large majority of inversion sprains, and approximately 20–40% of individuals progress to chronic lateral ankle instability, generating a substantial burden in both athletic and general populations across all regions. The lateral ligament complex. Three distinct ligaments provide sequential restraint through the range of ankle motion:

Biomechanics. The lateral ligaments provide roughly 30–40% of total ankle stability; osseous congruity (the mortise) and the surrounding musculature provide the remainder. Functionally the ligaments work as a sequence: in plantarflexion the ATFL is vertical and the primary inversion restraint, while in dorsiflexion the ATFL relaxes and the CFL becomes the principal restraint to inversion and subtalar tilt. Because the CFL bridges both the talocrural and subtalar joints, combined ATFL plus CFL deficiency produces clinically meaningful talar tilt and subtalar instability, whereas isolated CFL insufficiency rarely causes symptomatic instability. This position dependence underpins clinical testing — the anterior drawer (ATFL) is assessed in slight plantarflexion and the talar tilt (CFL) in neutral/dorsiflexion. Anatomic repair restores this normal kinematic sequence; non-anatomic tenodeses do not, which is why they over-constrain the subtalar joint and reduce the inversion-eversion arc. Pathophysiology — acute sprain to chronic instability. An initial injury causes ligament elongation (3–5 mm) rather than complete disruption in many cases. Repetitive giving-way episodes drive progressive attenuation, capsular laxity and proprioceptive deficits, with associated pathology developing in 40–70% (osteochondral lesions around 35%, peroneal tendon pathology around 25%, sinus tarsi syndrome around 20%). Reported outcomes. The Broström-Gould achieves 85–95% good-excellent satisfaction, return to pre-injury sport in 80–90% of athletes at an average 4–6 months, and recurrence of 5–10% at 5 years (rising to 12–15% at 10 years). Non-anatomic reconstructions show lower success (75–85%) and higher stiffness (20–30%). Patient-reported AOFAS Ankle-Hindfoot scores average 88–92 postoperatively (from 55–65 preoperatively) and FAAM scores average 85–90% of maximum. Guidelines, registries and global practice. There is broad international agreement on the core principles — confirm mechanical instability, exhaust structured rehabilitation, correct hindfoot varus, and prefer anatomic repair. Genuine variation is mainly in the uptake of arthroscopic versus open repair and the threshold for suture-tape augmentation.

Practice variation. Arthroscopic Broström is increasingly adopted in high-volume sports-medicine centres (faster weight-bearing, lower wound-complication rate) but remains technically demanding and less available in lower-resource settings, where open repair predominates. Allograft availability and regulation differ markedly by region, influencing the choice between allograft reconstruction and autograft (peroneal/hamstring) tenodesis for revision cases.