How severe was the chronic right‑ankle instability with anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) degeneration, anterior impingement lesions, and synovitis before surgery?

Severity Assessment of Pre-Operative Right Ankle Instability

This ankle demonstrated moderate-to-severe chronic instability with significant intra-articular pathology requiring comprehensive surgical intervention. The operative findings reveal a constellation of pathologic changes characteristic of advanced chronic ankle instability that had progressed beyond isolated ligamentous injury.

Ligamentous Injury Severity

The presence of degeneration and partial tears of both the ATFL and CFL indicates Grade 2-3 chronic instability requiring dual ligament repair. 1

• Complete rupture of the ATFL occurs in 64% of chronic ankle instability cases, while CFL involvement occurs in 41% 2
• When both ATFL and CFL demonstrate degeneration and partial tears requiring combined repair, this represents a more severe instability pattern associated with higher ankle activity scores and worse prognosis 1
• The poor tissue quality noted intraoperatively ("degeneration and partial tears") is a characteristic finding in chronic instability requiring both ligament repairs, indicating prolonged mechanical stress and failed healing 1
• Patients requiring combined ATFL and CFL repair demonstrate significantly higher rates of associated intra-articular pathology compared to those requiring ATFL repair alone (66.7% vs 20%) 1

Intra-Articular Pathology Burden

The "significant impingement lesions" requiring debridement and synovectomy indicate chronic inflammatory changes present in 38-60% of chronic ankle instability cases. 2, 3

• Anterior impingement with synovitis requiring thorough synovectomy occurs in 38-60% of chronically unstable ankles 2, 3
• Impingement at the trifurcation area requiring debridement suggests advanced soft tissue proliferation from repetitive microtrauma 3
• The absence of full-thickness cartilage defects is favorable, as cartilage lesions occur in 54% of chronic instability cases and predict worse outcomes 2
• However, the presence of significant synovitis and impingement tissue requiring arthroscopic debridement indicates the ankle had progressed beyond simple ligamentous laxity to include secondary inflammatory pathology 3

Clinical Severity Indicators

The requirement for a 1-1.5 cm advancement of the ligamentous complex during the modified Broström-Gould procedure indicates substantial tissue elongation and chronic mechanical failure. 4

• Standard Broström repairs typically require minimal advancement; the 1-1.5 cm advancement documented here reflects significant ligamentous attenuation from chronic instability 4
• The need for five separate 2-0 Ethibond mattress sutures (rather than the typical 2-3) suggests extensive tissue involvement requiring robust fixation 4
• Addition of the Gould modification (extensor retinaculum reinforcement) is reserved for cases with poor tissue quality or higher mechanical demands, confirming this was not a simple acute injury 4
• The peroneal tendons being "of fair quality" (rather than good or excellent) suggests chronic compensatory stress, though they did not require repair 5

Comparative Severity Context

This ankle falls into the category requiring surgical intervention based on established criteria for chronic instability with deformity and high risk of complications. 6

• The International Working Group on the Diabetic Foot (IWGDF) guidelines recommend surgical intervention for ankle instability with deformity that cannot be stabilized in casting or causes impending ulceration 6
• While these guidelines address Charcot neuroarthropathy, the principle applies: instability with structural changes (impingement, synovitis, ligament degeneration) warrants surgical correction to prevent progression 6
• The British Journal of Sports Medicine confirms that 20% of acute ankle sprains progress to chronic instability requiring surgical intervention, placing this patient in the more severe subset 6, 4

Prognostic Implications

The combination of dual ligament involvement, significant intra-articular pathology, and tissue degeneration places this ankle at elevated risk for osteoarthritis development despite surgical correction. 1, 5

• Chronic instability with associated intra-articular lesions increases osteoarthritis risk, with medial gutter changes (noted in 62.5% of dual ligament repair cases) being particularly concerning 1
• The presence of impingement lesions and synovitis indicates the ankle had sustained repetitive injury over time, creating a pro-inflammatory environment that accelerates cartilage degeneration 5
• Early surgical intervention was appropriate, as delaying treatment in chronic instability allows progression of cartilage damage and development of irreversible osteoarthritis 5

Common Pitfalls in Severity Assessment

• Underestimating severity based on absence of full-thickness cartilage defects: The presence of significant soft tissue pathology (impingement, synovitis) and dual ligament involvement indicates advanced disease even without cartilage loss 2, 3
• Assuming all chronic ankle instability is equivalent: This case required both ATFL and CFL repair with advancement, placing it in a more severe category than isolated ATFL injuries 1
• Overlooking tissue quality indicators: The documented "degeneration" and "fair quality" tissues predict higher complication rates and need for more robust repair techniques 1, 4