Was surgery the appropriate treatment for a patient with chronic right‑ankle instability, degeneration and partial tears of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL), and anterior impingement lesions with synovitis?

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Was Surgery the Right Choice for This Ankle?

Yes, surgery was appropriate for this patient with chronic right-ankle instability, degeneration and partial tears of both the ATFL and CFL, and anterior impingement lesions with synovitis, because these findings represent failed conservative management requiring surgical stabilization. 1

Why Surgery Was Indicated in This Case

Failed Conservative Management

  • Surgery is reserved exclusively for patients with chronic ankle instability who have not responded to comprehensive exercise-based physiotherapy programs. 1 The presence of chronic instability with structural ligament damage (partial tears of both ATFL and CFL) indicates that conservative treatment has already failed. 2

  • The British Journal of Sports Medicine states that 60-70% of individuals respond well to non-surgical treatment programs, but this patient falls into the 30-40% who develop chronic ankle instability despite initial treatment. 1, 2

Structural Pathology Requiring Repair

  • The combination of ATFL and CFL involvement is a critical indicator for surgical intervention. Research demonstrates that patients requiring both ATFL and CFL repair exhibit characteristic findings including high rates of chondral/osteochondral lesions, osteoarthritis changes, and poor quality of ligament remnants. 3

  • The presence of anterior impingement lesions with synovitis represents associated intra-articular pathology that benefits from arthroscopic treatment. Arthroscopic surgery allows comprehensive assessment of ligament lesions, detection and treatment of associated lesions (such as impingement and synovitis), and repair of damaged ligaments. 4

  • Degeneration and partial tears of both the ATFL and CFL indicate poor tissue quality that will not heal with conservative measures alone. 3

Evidence Supporting Surgical Decision

Outcomes of Surgical Treatment

  • More recent studies show that outcomes in terms of recovery of ankle activity and instability are significantly better for surgical treatment than for functional treatment in chronic cases. 1 A meta-analysis of 12 RCTs with 1,413 patients demonstrated this superiority (Level 1 evidence). 1

  • Surgery is superior at decreasing the prevalence of recurrent ankle sprains (RR 0.72,95% CI 0.55-0.94), which is important because recurrent sprains increase the risk for subsequent development of osteoarthritis. 1

  • A prospective multicentre study of 286 patients undergoing arthroscopic treatment for chronic ankle instability showed overall patient satisfaction of 8.5/10, with AOFAS scores improving from 62.1 to 89.2 and Karlsson scores improving from 55 to 87.1. 4

Addressing Multiple Pathologies

  • The anterior impingement lesions and synovitis identified in this patient are best addressed surgically. Arthroscopic treatment allows simultaneous management of ligament instability, impingement lesions, and synovitis in a single procedure. 4

  • Clinical signs of anterior impingement develop in 25% of patients with chronic ankle instability, with 82% showing radiographic confirmation. 2 This patient's documented impingement lesions represent established structural pathology requiring surgical debridement.

Surgical Approach Considerations

Both ATFL and CFL Repair Required

  • When both ATFL and CFL are involved with degeneration and partial tears, repair of both ligaments should be performed to ensure complete correction of instability. 3 Research shows that ATFL repair alone is insufficient to stabilize the ankle when the CFL is also compromised. 3

  • Biomechanical studies confirm that sectioning the CFL causes significant increases in talar tilt at both 0° and 30° of plantarflexion, demonstrating the CFL's critical role as a primary stabilizer. 5

  • The importance of addressing the CFL to correct talar tilt instability is well-established. 5 Complete native stability may not be attainable with ATFL repair alone when both ligaments are damaged. 5

Arthroscopic vs. Open Technique

  • Arthroscopic treatment has become a method of choice for chronic ankle instability because it allows comprehensive assessment, treatment of associated lesions, and ligament repair with significantly lower complication rates. 4

  • The rate of cutaneous complications is at least halved compared to open surgery, with neurological complications occurring in 10% of patients (mostly transient dysesthesia). 4

  • Cutaneous or infectious complications requiring surgical revision develop in only 4.2% of patients with arthroscopic treatment. 4

Common Pitfalls and Caveats

Ensuring Adequate Conservative Trial First

  • The most critical pitfall is performing surgery without first attempting comprehensive exercise-based physiotherapy. 1, 2 However, the presence of chronic instability with structural ligament damage suggests this patient has already failed conservative management.

  • Functional treatment should include supervised exercise therapy focusing on proprioception, strength, coordination, and functional training for 4-6 weeks combined with functional support. 2 Surgery is only indicated after this has been attempted and failed.

Postoperative Rehabilitation

  • Even after successful surgery, a period of immobilization followed by protected rehabilitation is essential. 5 None of the repair methods at time zero restore kinematics to the intact state, emphasizing the importance of postoperative protection. 5

  • Findings suggest that further consideration should be given to augmentation techniques (such as suture tape) when tissue quality is poor, as this limits postoperative motion in anterior drawer testing. 5

Long-Term Osteoarthritis Risk

  • Recurrent ankle sprains increase the risk for subsequent development of osteoarthritis. 1 Surgery's superiority in preventing recurrent sprains makes it particularly important for patients with chronic instability and existing degenerative changes. 1

  • Up to 40% of individuals who sustain lateral ankle sprains develop chronic ankle instability, and patients with remote ligament sprains face a 5-40% risk of progression to ankle osteoarthritis. 2

Alternative Consideration

  • The only scenario where surgery might not have been appropriate is if this patient had not yet undergone a comprehensive 4-6 week supervised exercise-based physiotherapy program. 1, 2 However, the presence of chronic instability with structural degeneration and partial tears strongly suggests conservative treatment has already been attempted and failed.

  • Secondary surgical repair, even years after an injury, has results comparable to those of primary repair, so delaying surgery to ensure adequate conservative trial does not compromise outcomes. 6

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Chronic Ankle Instability Treatment Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Research

Characteristics of Chronic Ankle Instability Requiring Both Anterior Talofibular and Calcaneofibular Ligament Repair.

The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, 2022

4
Research

Arthroscopic treatment of chronic ankle instability: Prospective study of outcomes in 286 patients.

Orthopaedics & traumatology, surgery & research : OTSR, 2018

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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