Some authors underscore the need of identifying precisely the amount of ligaments involved and to provide either anatomical repair or ligament reconstruction according to the quality of the ligament remnants. For this reason, hybrid techniques have been proposed.

Kennedy et al. combined ATFL reconstruction with a split peroneus longus tendon graft direct anatomical repair and plication of the CFL [56]. Similarly, Peterson et al. suggest in patients with significant ligamentous instability, increased BMI, or failed primary repair a combination of the Broström-Gould repair augmented with a free autogenous split peroneus longus tendon graft [57].

In addition, combined arthroscopic and open procedures have been proposed in order to improve the diagnosis and management of intra-articular lesions and allow minimally invasive reconstruction of the lateral ligament complex [58]. Nery et al. recently described a technique providing arthroscopic debridement of the ATFL adhesions followed by arthroscopic-assisted anchor fixation of the lateral capsular and ligament remnants over the anteroinferior aspect of the lateral malleolus. Results were satisfying in most patients at 10 years follow-up with a 5 % failure rate [58].

Rehabilitation protocols following surgical repair usually consist of brace immobilization in a neutral position with non-weight-bearing for 2–3 weeks. Then peroneal muscle strengthening, proprioceptive, and complete ankle range of motion (ROM) exercises are started. Immobilization with cast or brace and non-weight-bearing are important in order to prevent lengthening of the treated tissue following arthroscopic repair and to allow the healing and reconstitution process to occur unimpeded. Various reports suggest non-weight-bearing for 2–3 weeks [40–43, 45, 52]. de Vries et al. [44] propose the use of a compression bandage only for 3–5 days and early weight-bearing 5–7 days postoperatively. Articular stiffness may result from prolonged brace immobilization and delayed functional rehabilitation program, and there is evidence that after surgical reconstruction, early functional rehabilitation appears to be superior to 6 weeks immobilization in restoring early function [38]. Return to sports is usually permitted 3 months postoperatively. Kim et al. [52] suggest return to straight running and functional activities 8 weeks postoperatively, and cutting and sport-specific drills are allowed by week 12. However, patients should be instructed to avoid premature return to sport activity that could affect the outcome.