In a 28‑year‑old male with generalized ligamentous laxity, a prior right Broström‑Gould repair with anterior ankle arthroscopy and concentrated bone‑marrow aspirate, who now has recurrent lateral ankle instability after a minor inversion injury and only mild improvement from a platelet‑rich plasma injection, what is the recommended long‑term management?

Recommended Long-Term Management for Recurrent Lateral Ankle Instability with Generalized Ligamentous Laxity

Proceed with the planned right ATFL reconstruction with internal brace augmentation, CFL shortening and plication, anterior ankle nano-arthroscopy with debridement, and concentrated bone marrow aspirate (cBMA), as the modified Broström procedure has a significantly higher failure rate (11.4% vs 1.8%) in patients with generalized ligamentous laxity and this patient has already failed both the initial Broström repair and subsequent PRP injection. 1

Why Conservative Management Has Failed

This patient's clinical course demonstrates the predictable failure pattern of standard ligamentous repair in the setting of generalized hypermobility:

• The modified Broström procedure achieves only 85-95% success rates in the general population, but patients with generalized joint laxity show significantly inferior outcomes with mean final Karlsson scores of 87.4 (vs 94.1 in patients without laxity), higher residual talar tilt angles (7.3° vs 5.2°), and a six-fold higher failure rate (11.4% vs 1.8%). 1

• His rheumatology-confirmed hypermobility disorder explains why the native ATFL repair elongated after the minor inversion injury—the repaired collagenous tissue lacks the tensile strength to maintain stability under physiologic loads. 2

• PRP injection provided only "mild symptomatic improvement" because biologic augmentation alone cannot compensate for mechanical insufficiency in a structurally incompetent ligament; while PRP accelerates early healing and improves ligament quality on MRI in acute grade II sprains, it does not restore mechanical restraint in chronic instability with established ligamentous elongation. 3

• Physical examination findings of "increased ankle ROM without firm endpoint" and "loose subtalar joint" confirm mechanical instability that requires surgical reconstruction rather than continued conservative measures. 4

Evidence Supporting Internal Brace Augmentation in Hypermobility

The internal brace (suture tape) addresses the fundamental problem in generalized ligamentous laxity—it provides a non-biologic mechanical checkrein that prevents ligamentous fatigue and re-elongation:

• Standard anatomic repair relies on host collagen to maintain stability, which is inherently deficient in hypermobility disorders. 2

• Tendon reconstruction procedures (Chrisman-Snook, Evans) sacrifice the peroneus brevis, result in loss of talocrural and subtalar motion, prolong recovery, and carry higher rates of adjacent nerve injury—making them less desirable than internal brace augmentation, which preserves native anatomy while adding mechanical strength. 2

• The internal brace technique allows native ligament ingrowth over a permanent synthetic scaffold, combining the motion-preserving advantages of anatomic repair with the mechanical strength previously achievable only through tendon reconstruction. 5

Role of Anterior Ankle Arthroscopy

Performing anterior ankle nano-arthroscopy is critical because:

• 70% of patients with chronic lateral ankle instability harbor osteochondral lesions of the talus, which MRI often fails to detect. 4

• Repeated micro-displacement of the talus—even 1 mm—causes cartilage malalignment and accelerates post-traumatic ankle arthritis, making identification and treatment of intra-articular pathology essential for long-term joint preservation. 4

• Arthroscopic debridement of impinging soft tissue or bony impingement improves ankle range of motion and addresses anterior impingement, which develops in 25% of patients with chronic instability. 4

Role of Concentrated Bone Marrow Aspirate

cBMA augmentation provides:

• A reservoir of growth factors, anti-inflammatory cytokines (especially interleukin-1 receptor antagonist protein), and mesenchymal stem cells that enhance healing of the reconstructed ligament and protect articular cartilage. 4

• Biologic augmentation of the surgical construct in a patient whose native healing capacity is compromised by collagen disorder. 5

Why Continued Conservative Management Is Inappropriate

This patient has exhausted evidence-based conservative options:

• He completed the initial post-Broström rehabilitation protocol and experienced three months of improvement before mechanical failure. 4

• He underwent PRP injection, which provided only mild benefit and does not address the underlying mechanical instability. 3

• Supervised exercise therapy, balance training, and bracing prevent recurrent sprains in patients with intact ligamentous restraints (RR 0.37 for recurrence prevention, RR 0.53 for brace/tape use), but these interventions cannot compensate for structural ligamentous insufficiency with demonstrable mechanical laxity on examination. 6

• Up to 40% of patients develop chronic ankle instability despite initial treatment, and 5-46% report long-term pain at 1-4 years—this patient is already in that cohort and requires definitive mechanical stabilization. 4

Surgical Timing and Prognosis

Proceeding with surgery now is appropriate because:

• Delaying surgery allows continued micro-instability and cartilage damage, increasing the risk of post-traumatic ankle arthritis. 4

• The patient has returned seeking "reassurance regarding the status of his ankle and guidance on long-term management"—his symptoms are severe enough to prompt re-evaluation, indicating functional limitation despite conservative measures. 4

• Surgical reconstruction is superior to functional treatment for decreasing recurrent ankle sprain prevalence, which is critical given the osteoarthritis risk from repeated micro-displacement. 4

Common Pitfalls to Avoid

• Do not recommend another trial of physical therapy or bracing—this patient has mechanical instability confirmed on examination and has already failed conservative management; further delay risks progressive cartilage damage. 4

• Do not perform isolated arthroscopic ATFL repair without internal brace augmentation in a patient with generalized ligamentous laxity—the native tissue will re-elongate, as demonstrated by his post-Broström course. 1

• Do not omit the anterior ankle arthroscopy—failing to identify and treat osteochondral lesions leaves a major source of ongoing symptoms and accelerates arthritis. 4

• Ensure the patient understands the 6-week non-weightbearing and protected weightbearing protocol is mandatory—premature return to activity risks graft failure, especially in hypermobility. 4