Lateral ankle sprains are one of the most common reasons for patients to visit an emergency room.¹ Fortunately, patients with residual instability symptoms are often managed successfully with a rehabilitative exercise program and the use of a brace. Of these patients, approximately 20% will go on develop symptomatic chronic recurrent lateral ankle instability that interferes with recreational and daily activities.² Traditionally these patients have been surgically treated with an open lateral ankle ligament reconstruction technique, the most common of which is the Brostrom-Gould procedure.^{3, 4}

Due to the high percentage of pathologic findings discovered during ankle arthroscopy in patients with symptomatic lateral ankle instability,^{4, 5, 6, 7, 8} its concomitant use at the time of lateral ankle ligament reconstruction has become more frequent. The current use of ankle arthroscopy prior to open stabilization procedures is historically similar to its early use in the knee and shoulder. Initially, the open stabilization procedure was performed after arthroscopic evaluation of the joint. Both of these joints are now stabilized mainly through arthroscopic methods.

Previous reports of arthroscopic assisted ankle stabilization employing staples,⁹ secondary incisions for anchor placement,^{10, 11} or capsular shrinkage techniques^{12, 13, 14} described moderate early success. More recently, several authors have reported successful arthroscopic lateral ankle ligament reconstruction using bone anchor techniques.^{15, 16, 17}

Given the historical success of knee and shoulder joint arthroscopic stabilization procedures, along with additional recent success with arthroscopic assisted lateral ankle ligamentous reconstruction, the authors believe arthroscopic lateral ankle ligament reconstruction should be considered for patients with symptomatic chronic lateral ankle instability.

During the patient’s preoperative evaluation, it is important to evaluate the patient for any associated injuries, such as osteochondral lesions, peroneal tendon pathology, and syndesmotic instability. Some of these other conditions may be addressed at the time of arthroscopy. On the other hand, some conditions may require the surgeon to proceed with an open ligament reconstruction. All candidates for reconstruction should have a history of symptomatic lateral ankle ligamentous instability with recreational or daily activities. All patients should have clearly documented manual stress testing performed in the office. Although most patients will have increased laxity with anterior drawer and talar tilt testing, some patients will present with functional instability alone. These patients have instability symptoms with activities but do not have significant laxity on physical examination or manual stress testing.¹⁸ Although radiographic stress testing with strict criteria for instability is not required to identify patients with ankle instability,^{18, 19} it should be considered in every patient given its minimal cost and easily administered adjunct to the physical examination.²⁰ Osteochondral injuries of the talus or peroneal tendon pathology can usually be treated concomitantly and do not preclude an arthroscopic approach. However, the presence of severe deformity, syndesmotic injury, deltoid ligamentous instability, or severe subtalar instability may necessitate an open approach.

Although this arthroscopic stabilization technique does not repair the calcaneofibular ligament (CFL), recent studies question the need for repair of the CFL.^{11, 21, 22, 23} In a biomechanical evaluation, Lee et al.²¹ found no significant difference between the modified Brostrom procedure of a single anterior talofibular ligament (ATFL) and a double ligament (ATFL and CFL) repair. A published clinical study of 30 patients who underwent an open modified Brostrom without CFL reconstruction revealed 28 patients with good to excellent results in terms of functional, clinical, and radiologic assessment.²² Because of its attachment to the calcaneus at the peroneal tubercle, the inferior extensor retinaculum (IER) most likely augments the stability of the construct. With this in mind, we believe the success of our arthroscopic technique in controlling talar tilt depends on capturing part of the IER during the procedure. Furthermore, Drakos et al.²⁴ have shown that a minimally invasive arthroscopic technique has equivalent biomechanical strength when compared to the traditional open Brostrom procedure.

The indications for arthroscopic lateral ankle ligament reconstruction are essentially the same as the indications for an open Brostrom-Gould type ligament reconstruction. In
all cases, patients should undergo an appropriate course of physical therapy focused on peroneal strengthening and proprioception reeducation. If the patient continues to have instability symptoms with normal peroneal motor strength, an arthroscopic lateral ligament reconstruction may be considered. Indications are:

At this point in time, this procedure is in its relative infancy so we believe understanding when not to perform this procedure is potentially more important than the indications alone. Therefore, we recommend avoiding an arthroscopic lateral ankle ligament reconstruction in the following conditions (Table 5-1).