All-inside Arthroscopic Repair of ATFL and CFL Separately for Chronic Lateral Ankle Instability in Conjunction with Subtalar Instability

All-inside Arthroscopic Repair of ATFL and CFL Separately for Chronic Lateral Ankle Instability in Conjunction with Subtalar Instability | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article All-inside Arthroscopic Repair of ATFL and CFL Separately for Chronic Lateral Ankle Instability in Conjunction with Subtalar Instability Weiwei Mao, Zhigao Jin, Wei Li, Ying Zhu, Weiqi Kong, Ying Wang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5886666/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Apr, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted 6 You are reading this latest preprint version Abstract Background Chronic lateral ankle instability (CLAI) is a common condition often associated with damage to the anterior talofibular ligament (ATFL). In cases where CLAI is accompanied by subtalar instability (STI) due to calcaneofibular ligament (CFL) injury, the optimal surgical approach remains controversial. While isolated ATFL repair has been shown to effectively restore ankle joint stability, it may be insufficient to address the subtalar joint instability caused by CFL damage. This study aimed to evaluate the clinical importance of CFL repair by comparing the outcomes of isolated ATFL repair versus combined ATFL and CFL repair. Methods A retrospective cohort study was conducted involving patients diagnosed with CLAI in conjunction with STI from January 2018 to January 2022. Participants were divided into two groups: one underwent isolated ATFL repair (ATFL group), and the other underwent combined ATFL and CFL repair (ATFL + CFL group). Clinical outcomes were assessed using the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS-AH), Karlsson Ankle Functional Score (KAFS) and Visual Analog Scale (VAS) scores, while radiological outcomes were evaluated by MRI and stress radiographs. Results All the functional scores significantly improved in both groups post-surgery. However, the ATFL + CFL group demonstrated superior functional recovery, with higher AOFAS scores and greater reductions in VAS pain scores compared to the ATFL group. Radiological evaluation indicated better restoration of subtalar joint stability in the ATFL + CFL group. At the final follow-up, 3 cases of recurrent instability were observed in the isolated ATFL repair group. No significant difference in other complication rates was observed between the two groups. Conclusion The study demonstrated the importance of CFL repair in patients with CLAI in conjunction with STI. While isolated ATFL repair is effective for ankle joint stability, combined ATFL and CFL repair offers superior outcomes by addressing both ankle and subtalar joint instability. These findings suggest that CFL repair should be considered in surgical planning for patients with STI to optimize functional recovery and long-term stability. Level of Evidence Level III. subtalar instability chronic lateral ankle instability anterior talofibular ligament calcaneofibular ligament arthroscopic Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Chronic lateral ankle instability (CLAI) is one of the most common injuries in sports medicine, with a high incidence in both athletes and the general population. 1 – 3 It is primarily associated with damage to the anterior talofibular ligament (ATFL). 4 , 5 However, studies have shown that approximately 20–25% of patients with acute ankle sprains or chronic lateral instability also experience injury to the calcaneofibular ligament (CFL). 6 , 7 As an essential component of the lateral ligament complex, the CFL plays a critical role in maintaining stability not only at the ankle joint during dorsiflexion but also in providing dynamic stability to the subtalar joint. 8 – 10 Biomechanically, the CFL spans both the ankle and subtalar joints, functioning as a key stabilizer against excessive inversion and rotational forces. 11 Therefore, damage to the CFL may therefore compromise the structural integrity of both joints, resulting in not only ankle instability but also subtalar instability (STI). 12 For cases of isolated CLAI, arthroscopic repair of the ATFL alone has typically achieved satisfactory clinical outcomes. Numerous studies have confirmed that isolated ATFL repair can effectively alleviate symptoms and improve joint function, with additional CFL repair having no significant effect on the overall outcome. 13 – 17 However, this perspective lacks consideration of subtalar stability. The inferior fascicle of the ATFL and the CFL are connected by fibers, so repairing the ATFL can partially tension the CFL. 18 , 19 However, this repair is insufficient to fully tighten the CFL, particularly when the ligament is extremely lax, which is an important reason why some patients keep complaining of their hindfoot instability after ankle stabilization surgery. 20 , 21 In this context, the necessity of CFL repair remains a key clinical question. This study aims to evaluate whether combined repair of the ATFL and CFL offers superior outcomes compared to isolated ATFL repair in patients with CLAI accompanied by STI. We propose the following hypotheses: 1. Simply repairing the ATFL cannot restore STI. 2. Separately repairing the ATFL and CFL can simultaneously reconstruct the stability of the ankle and subtalar joints. Methods A retrospective analysis was conducted on patients who underwent arthroscopic ligament repair surgery for CLAI combined with STI between January 2018 and January 2022. This study was approved by the ethics committee of our hospital. Written informed consent was obtained from all patients. All surgeries were performed by the same surgeon. Surgical indications for this procedure included patients who presented with a history of recurrent lateral ankle sprains and demonstrated persistent symptoms of instability despite at least 6 months of non-operative treatment (physical therapy, bracing, and non-steroidal anti-inflammatory drugs). These patients typically experienced frequent ankle sprains (3 or more episodes over the past 12 months) and exhibited signs of both ankle and subtalar joint instability, as confirmed by clinical tests (positive anterior drawer and inversion stress tests) and radiographic imaging (positive subtalar stress radiographs). 22 Furthermore, MRI findings of ligamentous damage in both the ATFL and CFL were essential for confirming the need for surgical intervention. Patient Selection The criteria included in our study were as follows: (1) Patients with CAI combined with STI who underwent arthroscopic treatment after failed non-surgical treatment, (2) Patients who completed a ≥ 2-year postoperative follow-up with complete clinical evaluation data. The exclusion criteria were as follows: (1) previous surgery of the affected limb, (2) lateral malleolar fracture on the affected side, (3) significant bone deformities in the affected ankle or foot, (4) poor ligament quality during surgery that was not suitable for repair, (5) chronic ankle osteoarthritis, (6) BMI > 30, and (7) abnormalities of the interosseous talocalcaneal ligament (ITCL) and/or cervical ligament (CL) on MRI. Group Division Patients were divided into two groups based on whether additional CFL repair was performed following arthroscopic ATFL repair for CLAI combined with STI: ATFL group underwent arthroscopic ATFL repair alone, while ATFL + CFL group underwent arthroscopic ATFL repair with additional CFL repair. Between January 2018 and June 2020, patients with CLAI combined with STI were treated exclusively with isolated arthroscopic ATFL repair. After July 2020, combined arthroscopic ATFL and CFL repair was adopted. The reason for this procedural change was concern that isolated ATFL repair might be insufficient to restore subtalar joint stability. To ensure subtalar joint stability and improve the long-term outcomes of surgery, the all-inside arthroscopic combined ATFL and CFL repair technique was used after July 2020. Operative Technique The patient was positioned in the supine position, with an inflatable tourniquet applied to the proximal thigh for hemostasis. Three arthroscopic portals were marked on the skin. The P1 portal was located approximately 1 cm proximal to the ankle joint line and just lateral to the anterior tibial tendon. This portal served as the viewing portal. The P2 portal was located approximately 1 cm distal to the ankle joint line and just lateral to the peroneus tertius tendon. This portal was used as the working portal. The P3 portal was located at the tarsal sinus and could be used as both the working and the viewing portal (Fig. 1 ). Diagnostic arthroscopy was performed to debride the hyperplastic synovium and intra-articular scar tissue, and the concomitant lesions were treated at the same time. Arthroscopic Anatomic ATFL Repair. Debridement of the ATFL footprint area of the lateral malleolus, a probe was used to explore and confirm the significant laxity of the ATFL (Fig. 2 A). A 3.0-mm absorbable suture anchor (Smith & Nephew, London, UK) was inserted into the debrided ATFL footprint on the fibula using the P3 portal (Fig. 2 B). The SutureLasso (Arthrex, Naples, FL) was inserted through the P3 portal from the lower lateral to the upper medial side of the ATFL (Fig. 2 C). The wire loop was retrieved from the P3 portal with a grasper and passed through one suture. Then, the SutureLasso was withdrawn through the upper medial to the lower lateral direction, following the same approach. The wire loop of the SutureLasso pulled the thread of the suture out of the P3 portal from the midportion (Fig. 2 D). The end of the suture was passed through its own midportion to form a loop, then locked with a slip-knot technique (Fig. 2 E). Additional CFL Repair. After ATFL anatomic repair, switched to the P2 portal as the working portal and the P3 portal as the viewing portal, the tarsal sinus was debrided as well, exposing the distal joint, ITCL, and CL. The ITCL was identified as normal with the probe (Fig. 3 A), ruling out rotational instability of the subtalar joint. Dissection was then performed along the medial side of the peroneal tendons to expose the CFL. The probe was used to assess the integrity and relaxation of the CFL and the posterior articular surface of the subtalar joint, both of which were confirmed to be lax, further indicating subtalar instability (Fig. 3 B-C). A 3.0-mm absorbable suture anchor was inserted at the CFL footprint on the calcaneus (Fig. 3 D). The CFL was tightened using the same method as previously described (Fig. 3 E-G). The patient was immobilized in a neutral position with a short leg cast for 3–4 weeks. Physical therapy and range of motion exercises were initiated 6 weeks postoperatively. Additionally, the patient engaged in ankle joint proprioceptive training for 2–3 months. Clinical Evaluations The assessment of clinical outcomes included preoperative and during the final follow-up (at least 24 months postoperatively) evaluations using the Visual Analog Scale (VAS), American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS-AH), and the Karlsson Ankle Functional Score (KAFS). 23 Radiographic Evaluations Stress Radiography. All patients underwent preoperative weight-bearing anteroposterior, lateral radiographs of the foot and ankle, as well as hindfoot alignment views to investigate the presence of malalignment. 24 , 25 Stress radiographs were recorded using a Telos device (Telos GmbH, Marburg, Germany) at both preoperative and final follow-up evaluations (Fig. 4 ). Standardized methods were used for all stress radiographs, measuring the talar tilt angle and anterior talar translation to assess ankle stability, as well as the subtalar tilt angle and calcaneal medial translation to evaluate subtalar joint stability. All measurements were conducted using a digital Neusoft PACS/RIS imaging system by two orthopedic surgeons, and the results were averaged for accuracy. MRI Scan. All patients were performed with a 1.5-T MRI scanner (Artoscan, Esca, Gscan) preoperatively and at the one-year postoperative follow-up to confirm ligament integrity (Fig. 5 ). The normal ATFL is identified as a linear, thin, low-signal-intensity band on T1-weighted axial images. 26 The CFL is identified as a round, uniform, low-signal-intensity structure on cross-sectional images. 27 According to the criteria proposed by Joshy et al. 28 chronic ligament tears or dysfunction were diagnosed if the ligament appeared invisible, discontinuous, or had a wavy or curved contour. Ligaments showing uniform low-signal intensity on imaging were considered normal. Statistical analysis All statistical analyses were performed using SPSS (version 22.0; SPSS Inc, Chicago, IL). The Shapiro-Wilk test was used to evaluate the normality of the data distribution. Continuous variables following a normal distribution were analyzed using an unpaired t -test, while the Mann-Whitney U test was applied for variables that did not meet normality assumptions. Paired data were analyzed using a paired t -test or Wilcoxon signed-rank test as appropriate. P < .05 was considered indicative of statistical significance. Results Patient Characteristics From January 2018 to January 2022, 35 patients with CLAI combined with STI were treated with arthroscopic ligament repair surgery at our hospital.1 case were excluded due to ankle fractures; 2 case underwent ligament reconstruction surgery due to poor ligament quality observed during surgery; 1 case had osteoarthritis and osteochondritis; and 1 case had a follow-up period of less than two years. Eventually, a total of 30 patients were included in the study and divided into two groups based on whether additional CFL repair was performed under arthroscopy: the isolated ATFL repair group (n=14) and the ATFL + CFL repair group (n=16). The baseline characteristics of the patients between the two groups showed no significant differences ( P > .05, Table 1). Table 1. Demographic characteristics of the patients. a. Demographics ATFL repair (n= 14) ATFL + CFL repair (n= 16) P Value Age, y, mean ± SD 33.4 ± 6.3 31.7 ± 4.5 .734 Sex: male, n (%) 8 (57.1) 10 (62.5) .626 BMI, mean ± SD 23.2 ± 2.3 22.9 ± 2.1 .887 Side: left, n (%) 5 (55.6) 8 (50.0) .854 Symptom duration, mo, mean ± SD 25.4 ± 3.8 27.8 ± 4.2 .768 Follow-up, mo, mean ± SD 24.3 ± 4.3 24.5 ± 3.9 .943 Concomitant intra-articular lesions, n (%) Osteochondral lesion Loose body Osteophytes Subfibular ossicle 3 (21.4) 2 (14.2) 2 (14.3) 4 (28.6) 4 (25.0) 3 (18.8) 4 (25.0) 5 (31.2) .748 .629 .128 .726 a Categorical variables are reported as n (%). Continuous variables are reported as mean ± SD. Abbreviations: BMI, body mass index. Clinical Outcomes The VAS scores, AOFAS-AH scores, and Karlsson-Peterson scores showed significant improvement at 12 months postoperatively and at the final follow-up in both groups compared to preoperative values ( P < .01, Table 2). At 12 months, the ATFL + CFL repair group demonstrated significantly lower VAS scores (2.4 ± 0.6 vs. 3.5 ± 0.4) and higher AOFAS-AH scores (85.4 ± 7.2 vs. 76.8 ± 4.7) and Karlsson-Peterson scores (83.2 ± 10.8 vs. 74.4 ± 6.8) compared to the ATFL repair-only group ( P < .01). This trend persisted at the final follow-up, with the ATFL + CFL group showing superior VAS (2.2 ± 0.4 vs. 2.8 ± 0.7), AOFAS-AH (88.5 ± 2.9 vs. 78.1 ± 8.2), and Karlsson-Peterson scores (85.6 ± 5.9 vs. 77.8 ± 9.1) ( P < .01). These results indicate that although both groups achieved substantial improvements, the ATFL + CFL repair group consistently exhibited better pain relief and functional recovery. Table 2 Functional outcomes comparison of the two groups. a Functional Outcomes ATFL repair (n=14) ATFL + CFL repair (n=16) P Value Visual analog scale Preoperative 6.4 ± 1.2 6.7 ± 2.3 .354 12 mo 3.5 ± 0.4 2.4 ± 0.6 <.01 Final follow-up 2.8 ± 0.7 2.2 ± 0.4 <.05 P value (preoperative vs 12 mo) <.01 <.01 Karlsson-Peterson scores Preoperative 45.2 ± 7.3 42.1 ± 8.7 .673 12 mo 74.4 ± 6.8 83.2 ± 10.8 <.01 Final follow-up 77.8 ± 9.1 85.6 ± 5.9 <.01 P value (preoperative vs 12 mo) <.01 <.01 AOFAS-AH Preoperative 55.3 ± 7.1 57.8 ± 8.4 .735 12 mo 76.8 ± 4.7 85.4 ± 7.2 <.01 Final follow-up 78.1 ± 8.2 88.5 ± 2.9 <.01 P value (preoperative vs 12 mo) <.01 <.01 Continuous variables are reported as mean ± SD. Abbreviations: AOFAS-AH, American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale Radiographic Outcomes The radiological outcomes demonstrated significant improvements in both groups after surgical treatment (Table 3). Talar tilt angle (TTA), subtalar tilt angle (STA), and medial calcaneal translation (CMT) were significantly reduced at 12 months postoperatively and at the final follow-up compared to preoperative values ( P < .01). However, the ATFL + CFL repair group exhibited superior radiological outcomes compared to the ATFL repair-only group. At 12 months, the TTA was significantly lower in the ATFL + CFL group (4.4 ± 0.9°) compared to the ATFL-only group (6.2 ± 1.3°) ( P < .05), and this difference further widened at the final follow-up (4.3 ± 0.6° vs. 6.7 ± 0.7°, P < .01). Similarly, the STA at 12 months was substantially reduced in the ATFL + CFL group (4.1 ± 1.3°) compared to the ATFL-only group (7.8 ± 1.7°, P < .01), with this trend persisting at the final follow-up (4.2 ± 2.1° vs. 8.1 ± 2.2°, P < .01). Moreover, the CMT was markedly lower in the ATFL + CFL group (2.7 ± 1.4 mm) at 12 months compared to the ATFL-only group (5.8 ± 2.7 mm, P < .01), and this significant difference remained at the final follow-up (2.7 ± 0.8 mm vs. 6.1 ± 2.5 mm, P .05). At the one-year postoperative follow-up, MRI scans demonstrated successful ligament healing in both groups. The ATFL was visualized as a well-defined, linear structure with low signal intensity on T1-weighted axial images, while the CFL appeared as a consistent, rounded, low-signal-intensity band in cross-sectional views (Figures 5C-D). Table 3 Radiological outcomes comparison of the two groups. Radiological Outcomes ATFL repair (n=14) ATFL + CFL repair (n=16) P Value Talar tilt angle, degrees Preoperative 12.3 ± 2.1 11.9 ± 3.7 .734 12 mo 6.2 ± 1.3 4.4 ± 0.9 <.05 Final follow-up 6.7 ± 0.7 4.3 ± 0.6 <.01 P value (preoperative vs 12 mo) <.01 <.01 Anterior talar translation, mm Preoperative 11.8 ± 1.3 12.0 ± 0.8 .875 12 mo 5.3 ± 0.7 5.4 ± 1.2 .641 Final follow-up 5.4 ± 1.0 5.3 ± 1.1 .548 P value (preoperative vs 12 mo) <.01 <.01 Subtalar tilt angle, degrees Preoperative 11.3 ± 2.5 11.5 ± 2.4 .735 12 mo 7.8 ± 1.7 4.1 ± 1.3 <.01 Final follow-up 8.1 ± 2.2 4.2 ± 2.1 <.01 P value (preoperative vs 12 mo) <.01 <.01 Medial calcaneal translation, mm Preoperative 9.3 ± 2.7 9.1 ± 1.3 .817 12 mo 5.8 ± 2.7 2.7 ± 1.4 <.01 Final follow-up 6.1 ± 2.5 2.7 ± 0.8 <.01 P value (preoperative vs 12 mo) <.01 <.01 Continuous variables are reported as mean ± SD. Recurrence and Other Complications All patients had no incision-related complications, no nerve damage. However, at the final follow-up, 3 cases of recurrent instability with increased pain symptoms occurred in the isolated ATFL repair group, which later underwent ligament reconstruction surgery. No cases of recurrent instability were observed in the combined ATFL and CFL repair group. Discussion The most important finding of this study is that the combined arthroscopic repair of the ATFL and CFL yielded superior clinical and radiological outcomes compared to isolated ATFL repair in patients with CLAI accompanied by STI. This study demonstrated the importance of addressing subtalar instability in the surgical management of these patients. Failure to adequately treat combined instability of the ankle and subtalar joints may lead to recurrent sprains and hinder optimal functional recovery. There are many studies that have shown that subtalar instability is often associated with combined injuries to the ITCL, CL, and CFL, while isolated ligament injuries are less common. 29 , 30 However, in clinical practice, we have observed a number of cases where STI was caused by isolated CFL injuries. We hypothesize that this may be primarily due to the CFL being the first ligamentous structure injured during the development of subtalar instability, while the ITCL and CL are not yet significantly impacted in the early stages of the condition. 8 The combined failure of the CFL and the ATFL can cause lateral ankle instability in conjunction with subtalar instability. 31 Currently, there is no established method for diagnosing combined lateral instability of the ankle and subtalar joints. In our study, we diagnosed this condition through a comprehensive evaluation using clinical, radiographic, and arthroscopic assessments. First, we performed the anterior drawer and subtalar stress tests for a preliminary assessment. MRI subsequently confirmed injuries to both the ATFL and CFL, while the intrinsic ligaments of the subtalar joint were observed integrity. Initial assessment suggested the potential presence of combined lateral instability of the ankle and subtalar joints. Second, we used stress radiographs to assess lateral ankle instability by measuring anterior talar translation and the talar tilt angle. 32 According to the diagnostic criteria proposed by Jung et al. 22 for assessing lateral subtalar instability, we measured the subtalar tilt angle and calcaneal medial translation. Furthermore, we considered lateral laxation or opening of the subtalar joint was more significant than anterior translation of the calcaneus relative to the talus, since the intrinsic ligaments of the subtalar joint appeared normal and the medial deltoid ligament restricted anteroposterior movement. 33 Finally, intraoperative arthroscopy was used to definitively diagnose the lateral instability of the ankle and subtalar joints. Another important criterion we included was the positive findings of lateral subtalar instability under C-arm fluoroscopic subtalar stress views. 22 Before the formal surgery, we routinely performed subtalar stress tests under anesthesia using C-arm fluoroscopy. We considered continuous fluoroscopic imaging under anesthesia as a reliable method for diagnosing subtalar instability. Studies have highlighted the CFL's role in subtalar joint stability. Li et al. 9 reported that sectioning the CFL increases subtalar inversion during dorsiflexion, while Weindel et al. 34 found it causes excessive joint motion, leading to instability. Kamada et al. 35 further demonstrated that CFL repair can restore subtalar stability and alleviate symptoms. These findings align with our results, emphasizing the necessity of CFL repair to address subtalar instability in CLAI patients. In this study, we observed that ATFL repair alone improved ankle joint stability but failed to fully restore subtalar joint stability, as indicated by residual subtalar tilt angle and medial calcaneal translation. However, adding CFL repair significantly improved these radiological parameters, confirming the importance of addressing STI through additional CFL repair, further confirmed our hypothesis. There are few reports on the treatment of CLAI combined with STI. Lui et al. 36 described a technique for arthroscopic anatomical reconstruction of the ATFL and CFL to treat STI combined with CLAI, which helps reconstruct the stability of the ankle and subtalar joints. Choisne et al. 37 conducted simulations by sectioning and subsequently repairing key ligament structures on specimens. which significantly reduced subtalar and ankle inversion as well as subtalar internal rotation compared to the unstable condition. However, these studies are limited to technical and anatomical findings without clinical outcomes. This study is one of the first to comprehensively evaluate clinical and radiographic outcomes of arthroscopic ATFL and CFL repair in CLAI patients with STI. Postoperatively, both groups showed significant improvement in functional outcomes, but the ATFL + CFL group consistently outperformed the ATFL group in terms of pain relief and joint stability. There were several limitations in this study. First, the preoperative diagnosis of STI remains challenging due to its reliance on stress radiographs, MRI, and intraoperative findings, which require expertise and may not be universally available. Second, the retrospective design and relatively small sample size limit the generalizability of the findings. Future studies with larger cohorts and prospective designs are needed to validate these results. Third, the follow-up period was brief, potentially affecting the long-term validity of the results. Finally, the study did not include cases involving other critical ligaments of the subtalar joint, such as the ITCL and CL. If these ligaments are injured, repairing the CFL alone may be insufficient to restore subtalar joint stability. 38 Further comprehensive research is required to address these limitations and enhance our understanding of effective treatments for instability of the ankle and subtalar joints. Conclusion The combined arthroscopic repair of the ATFL and CFL provides superior clinical and radiographic outcomes compared to isolated ATFL repair in managing CLAI with STI. This approach effectively restores stability in both the ankle and subtalar joints, improves functional recovery, and reduces pain. CFL repair should be considered in surgical planning to optimize outcomes and minimize the risk of recurrent instability. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of the Second Affiliated Hospital of Soochow University (JD-HG-2024-082), and all patients provided written informed consent. Consent for publication Informed consent was obtained from all the patients in this study for the article to be published. Availability of data and materials The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study is supported by the Open Research Fund of the State Key Laboratory of Biotherapy, grant NO. (SKLB202409); the Project of Suzhou Sports Bureau, grant NO. (TY2024-103); the Project of State Key Laboratory of Radiation Medicine and Protection, Soochow University, grant NO. (GZK1202303); the Project of Second Affiliated Hospital of Soochow University 'Resident Standardized Training Capacity Building Support Program', grant NO. (ZPTJ-TD202405); the Project of 2023 'Four-Party Co-Construction' Special Project on Education and Teaching Reform of Suzhou Medical College, grant NO. (MX12301923). Author contributions MWW, JZG and LW contributed equally to this work and should be considered co-first authors. ZY collected and analysed the data. KWQ performed and analyzed the experiments. WY conceived and coordinated the study, designed. QJZ conceived and supervised the work, and wrote the paper. 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Oct 2023;31(10):4519-4525. doi:10.1007/s00167-022-07270-2 Hanada M, Hotta K, Matsuyama Y. Comparison Between the Simultaneous Reconstructions of the Anterior Talofibular Ligament and Calcaneofibular Ligament and the Single Reconstruction of the Anterior Talofibular Ligament for the Treatment of Chronic Lateral Ankle Instability. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons . May-Jun 2022;61(3):533-536. doi:10.1053/j.jfas.2021.01.012 Yang Y, Wu Y, Zhu W. Recent advances in the management of chronic ankle instability. Chinese journal of traumatology = Zhonghua chuang shang za zhi . Nov 7 2024;doi:10.1016/j.cjtee.2024.07.011 Ko KR, Lee WY, Lee H, Park HS, Sung KS. Repair of only anterior talofibular ligament resulted in similar outcomes to those of repair of both anterior talofibular and calcaneofibular ligaments. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA . Jan 2020;28(1):155-162. doi:10.1007/s00167-018-5091-3 Nakasa T, Ikuta Y, Sumii J, Nekomoto A, Kawabata S, Adachi N. Stepwise decision making for CFL repair in addition to arthroscopic ATFL repair yields good clinical outcomes in chronic lateral ankle instability regardless of the remnant quality. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association . Sep 2023;28(5):1087-1092. doi:10.1016/j.jos.2022.06.010 Vega J, Malagelada F, Dalmau-Pastor M. Arthroscopic all-inside ATFL and CFL repair is feasible and provides excellent results in patients with chronic ankle instability. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA . Jan 2020;28(1):116-123. doi:10.1007/s00167-019-05676-z Cordier G, Nunes GA, Vega J, Roure F, Dalmau-Pastor M. Connecting fibers between ATFL's inferior fascicle and CFL transmit tension between both ligaments. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA . Aug 2021;29(8):2511-2516. doi:10.1007/s00167-021-06496-w Yamamoto H, Yagishita K, Ogiuchi T, Sakai H, Shinomiya K, Muneta T. Subtalar instability following lateral ligament injuries of the ankle. Injury . May 1998;29(4):265-8. doi:10.1016/s0020-1383(97)00195-2 D'Hooghe P, Pereira H, Kelley J, et al. The CFL fails before the ATFL immediately after combined ligament repair in a biomechanical cadaveric model. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA . Jan 2020;28(1):253-261. doi:10.1007/s00167-019-05626-9 Jung HG, Park JT, Shin MH, Lee SH, Eom JS, Lee DO. Outcome of subtalar instability reconstruction using the semitendinosus allograft tendon and biotenodesis screws. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA . Aug 2015;23(8):2376-2383. doi:10.1007/s00167-015-3504-0 Luo X, Xue C, Xue Y, et al. Augmentation with the inferior extensor retinaculum may facilitate earlier recovery in all-inside arthroscopic management of chronic lateral ankle instability. Journal of orthopaedic surgery and research . Jan 11 2025;20(1):40. doi:10.1186/s13018-024-05437-w Burssens A, Peeters J, Buedts K, Victor J, Vandeputte G. Measuring hindfoot alignment in weight bearing CT: A novel clinical relevant measurement method. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons . Dec 2016;22(4):233-238. doi:10.1016/j.fas.2015.10.002 Kim J, Kim J, Kim S, Yi Y. Weight-Bearing CT for Diseases around the Ankle Joint. Diagnostics (Basel, Switzerland) . Jul 30 2024;14(15)doi:10.3390/diagnostics14151641 Chien AJ, Jacobson JA, Jamadar DA, Brigido MK, Femino JE, Hayes CW. Imaging appearances of lateral ankle ligament reconstruction. Radiographics : a review publication of the Radiological Society of North America, Inc . Jul-Aug 2004;24(4):999-1008. doi:10.1148/rg.244035723 Rosenberg ZS, Beltran J, Bencardino JT. From the RSNA Refresher Courses. Radiological Society of North America. MR imaging of the ankle and foot. Radiographics : a review publication of the Radiological Society of North America, Inc . Oct 2000;20 Spec No:S153-79. doi:10.1148/radiographics.20.suppl_1.g00oc26s153 Joshy S, Abdulkadir U, Chaganti S, Sullivan B, Hariharan K. Accuracy of MRI scan in the diagnosis of ligamentous and chondral pathology in the ankle. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons . Jun 2010;16(2):78-80. doi:10.1016/j.fas.2009.05.012 Gomes TM, Oliva XM, Viridiana Sanchez E, Soares S, Diaz T. Anatomy of the Ankle and Subtalar Joint Ligaments: What We Do Not Know About It? Foot and ankle clinics . Jun 2023;28(2):201-216. doi:10.1016/j.fcl.2022.12.003 Michels F, Vereecke E, Matricali G. Role of the intrinsic subtalar ligaments in subtalar instability and consequences for clinical practice. Frontiers in bioengineering and biotechnology . 2023;11:1047134. doi:10.3389/fbioe.2023.1047134 Keefe DT, Haddad SL. Subtalar instability. Etiology, diagnosis, and management. Foot and ankle clinics . Sep 2002;7(3):577-609. doi:10.1016/s1083-7515(02)00047-5 Lee SY, Kwon SS, Park MS, et al. Is there a Relationship between Bone Morphology and Injured Ligament on Imaging Studies and Laxity on Ankle Stress Radiographs? International journal of sports medicine . Dec 2016;37(13):1080-1086. doi:10.1055/s-0042-106300 Kato T. The diagnosis and treatment of instability of the subtalar joint. The Journal of bone and joint surgery British volume . May 1995;77(3):400-6. Weindel S, Schmidt R, Rammelt S, Claes L, v Campe A, Rein S. Subtalar instability: a biomechanical cadaver study. Archives of orthopaedic and trauma surgery . Mar 2010;130(3):313-9. doi:10.1007/s00402-008-0743-2 Kamada K, Watanabe S, Yamamoto H. Chronic subtalar instability due to insufficiency of the calcaneofibular ligament: a case report. Foot & ankle international . Dec 2002;23(12):1135-7. doi:10.1177/107110070202301211 Lui TH. Arthroscopic-assisted lateral ligamentous reconstruction in combined ankle and subtalar instability. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association . May 2007;23(5):554.e1-5. doi:10.1016/j.arthro.2006.07.038 Choisne J, Hoch MC, Alexander I, Ringleb SI. Effect of Direct Ligament Repair and Tenodesis Reconstruction on Simulated Subtalar Joint Instability. Foot & ankle international . Mar 2017;38(3):324-330. doi:10.1177/1071100716674997 Su T, Cheng XY, Zhu YC, et al. Arthroscopic Anatomic Reconstruction of the Interosseous Talocalcaneal Ligament Using a Gracilis Autograft for Subtalar Instability: 6- to 12-Year Retrospective Follow-up. Foot & ankle international . Dec 14 2024:10711007241293780. doi:10.1177/10711007241293780 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 15 Apr, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted Editorial decision: Revision requested 27 Mar, 2025 Reviews received at journal 26 Mar, 2025 Reviewers agreed at journal 24 Mar, 2025 Reviewers invited by journal 24 Mar, 2025 Submission checks completed at journal 24 Mar, 2025 First submitted to journal 24 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5886666","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":433370197,"identity":"0cec0989-181c-48ed-83f1-27c94c1362c8","order_by":0,"name":"Weiwei Mao","email":"","orcid":"","institution":"Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Weiwei","middleName":"","lastName":"Mao","suffix":""},{"id":433370203,"identity":"113be161-33b8-4bdf-8cff-d02ef93433c1","order_by":1,"name":"Zhigao Jin","email":"","orcid":"","institution":"Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Zhigao","middleName":"","lastName":"Jin","suffix":""},{"id":433370204,"identity":"ddaaecc6-d16c-4836-826a-94d673ee23e5","order_by":2,"name":"Wei Li","email":"","orcid":"","institution":"Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Li","suffix":""},{"id":433370209,"identity":"82687f6b-9842-4791-a2f4-0d0c563f9c02","order_by":3,"name":"Ying Zhu","email":"","orcid":"","institution":"Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Ying","middleName":"","lastName":"Zhu","suffix":""},{"id":433370210,"identity":"d2cd2a1b-9e2e-4fcd-a274-d0f84a923455","order_by":4,"name":"Weiqi Kong","email":"","orcid":"","institution":"Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Weiqi","middleName":"","lastName":"Kong","suffix":""},{"id":433370211,"identity":"34e9fae0-bdad-4433-91e6-9e6389500c97","order_by":5,"name":"Ying Wang","email":"","orcid":"","institution":"Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Ying","middleName":"","lastName":"Wang","suffix":""},{"id":433370215,"identity":"45191c9d-8739-479c-9b79-c18fb4358354","order_by":6,"name":"Jianzhong Qin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCklEQVRIie2Ru0oDQRSGJwyMzWTTzjaLj3BkYFQI5EFszjZbKVhJii0CwtpEfZWALzBwIGmGpLWwGBuxjI2kUmcTxWp3UwrOV8wF/u/M5TAWifxFOGOAYYZ6g+PPbMA5+f0V77hOb0QBe51Wp3rPFc9nK3mo2pLJom8vffk0Oj64pde8ElqTDH45PGtSUkoQcP7CT6fL4gSXMjPUt57Ni4tJ031IAqAgAY/nBvBKaVMX6U2oQ/kI41YRkD9cS1CdSl6RCor2WGE+4x1KulXuCMA5w9BZrSh8Mra8JVk5c7R5pxEspvptM7bZ4J7Ir8tho8IsEz+NE7/twKb4TuH+e8nXbcFIJBL5v3wBiwBfBd3/s18AAAAASUVORK5CYII=","orcid":"","institution":"Second Affiliated Hospital of Soochow University","correspondingAuthor":true,"prefix":"","firstName":"Jianzhong","middleName":"","lastName":"Qin","suffix":""}],"badges":[],"createdAt":"2025-01-23 08:53:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5886666/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5886666/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13018-025-05780-6","type":"published","date":"2025-04-15T15:57:38+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79179123,"identity":"9f7cb141-3248-4d79-b5a6-90a200f04601","added_by":"auto","created_at":"2025-03-25 10:11:41","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1216321,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic drawing illustrated arthroscopic portals on skin landmarks. ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; ATT, anterior tibial tendon; PTT, peroneus tertius tendon\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5886666/v1/3b47e62a53dec66bf65297ae.jpg"},{"id":79179795,"identity":"799670b2-ee6f-437d-83f0-9e172b92b66a","added_by":"auto","created_at":"2025-03-25 10:19:41","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":6194578,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative images of ATFL repair. A debridement and freshening of the ATFL footprint, revealing laxity. B the anchor placement in the distal lateral malleolus footprint. C the suturing process of the ATFL. D tension adjustment and knot tying. E confirms satisfactory ATFL tension using a probe. ATFL, anterior talofibular ligament; LM, lateral malleolus.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5886666/v1/6782fef394c74ed82ea7b468.jpg"},{"id":79179128,"identity":"22a914b3-3491-48a6-be54-f3f69f29a475","added_by":"auto","created_at":"2025-03-25 10:11:41","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1461079,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative images of CFL repair. A show that the ITCL is normal. B probe insertion into the posterior subtalar joint surface. C shows that the CFL is relaxed. D anchor placement at the CFL calcaneal footprint. E the suturing process of the CFL. F CFL tension adjustment and knot tying. G after CFL repair, the posterior joint surface of the subtalar joint closed. ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; ITCL, interosseous talocalcaneal ligament.\u003c/p\u003e","description":"","filename":"Figure3revised.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5886666/v1/4e8ca86b60dab7d14d6c8bed.jpg"},{"id":79179130,"identity":"e049443d-a2da-460e-a793-ad3a05dd26f3","added_by":"auto","created_at":"2025-03-25 10:11:41","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":3218829,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative radiographs of the patient. A weight-bearing anteroposterior view. B hindfoot long-axis view, both confirming normal alignment. C Broden’s stress view, showing increased talar and subtalar tilt angles and calcaneal medial translation. D anterior drawer stress radiograph, revealing anterior translation of the talus.\u003c/p\u003e","description":"","filename":"Figure4revised.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5886666/v1/c76be761cea28dd305a2e7ab.jpg"},{"id":79179788,"identity":"485f6840-da85-4aeb-aa17-1bab0ec6dbc1","added_by":"auto","created_at":"2025-03-25 10:19:41","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1005809,"visible":true,"origin":"","legend":"\u003cp\u003eA 25-year-old male presented with a sprained right ankle. (A, B) The preoperative axial T2-weighted and coronal PDW images showed that the ATFL was partially torn, appeared slender and incomplete, and the CFL appears thicker and blurred (arrows). (C, D) The axial T2-weighted and coronal PDW images at the 12-month postoperative follow-up showed that the ATFL and CFL had grown well with well-defined structures (arrows). ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament.\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5886666/v1/479b81583eed03a62009456b.jpg"},{"id":81050993,"identity":"026dcc0f-57f5-4e2e-90f1-eaaab84019d4","added_by":"auto","created_at":"2025-04-21 16:09:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":13568996,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5886666/v1/917aca7b-868f-435b-975c-7c0e1036814a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"All-inside Arthroscopic Repair of ATFL and CFL Separately for Chronic Lateral Ankle Instability in Conjunction with Subtalar Instability","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic lateral ankle instability (CLAI) is one of the most common injuries in sports medicine, with a high incidence in both athletes and the general population.\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e It is primarily associated with damage to the anterior talofibular ligament (ATFL).\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e However, studies have shown that approximately 20\u0026ndash;25% of patients with acute ankle sprains or chronic lateral instability also experience injury to the calcaneofibular ligament (CFL).\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e As an essential component of the lateral ligament complex, the CFL plays a critical role in maintaining stability not only at the ankle joint during dorsiflexion but also in providing dynamic stability to the subtalar joint.\u003csup\u003e\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Biomechanically, the CFL spans both the ankle and subtalar joints, functioning as a key stabilizer against excessive inversion and rotational forces.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Therefore, damage to the CFL may therefore compromise the structural integrity of both joints, resulting in not only ankle instability but also subtalar instability (STI).\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFor cases of isolated CLAI, arthroscopic repair of the ATFL alone has typically achieved satisfactory clinical outcomes. Numerous studies have confirmed that isolated ATFL repair can effectively alleviate symptoms and improve joint function, with additional CFL repair having no significant effect on the overall outcome.\u003csup\u003e\u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e However, this perspective lacks consideration of subtalar stability. The inferior fascicle of the ATFL and the CFL are connected by fibers, so repairing the ATFL can partially tension the CFL.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e However, this repair is insufficient to fully tighten the CFL, particularly when the ligament is extremely lax, which is an important reason why some patients keep complaining of their hindfoot instability after ankle stabilization surgery.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e In this context, the necessity of CFL repair remains a key clinical question.\u003c/p\u003e \u003cp\u003eThis study aims to evaluate whether combined repair of the ATFL and CFL offers superior outcomes compared to isolated ATFL repair in patients with CLAI accompanied by STI. We propose the following hypotheses: 1. Simply repairing the ATFL cannot restore STI. 2. Separately repairing the ATFL and CFL can simultaneously reconstruct the stability of the ankle and subtalar joints.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA retrospective analysis was conducted on patients who underwent arthroscopic ligament repair surgery for CLAI combined with STI between January 2018 and January 2022. This study was approved by the ethics committee of our hospital. Written informed consent was obtained from all patients. All surgeries were performed by the same surgeon. Surgical indications for this procedure included patients who presented with a history of recurrent lateral ankle sprains and demonstrated persistent symptoms of instability despite at least 6 months of non-operative treatment (physical therapy, bracing, and non-steroidal anti-inflammatory drugs). These patients typically experienced frequent ankle sprains (3 or more episodes over the past 12 months) and exhibited signs of both ankle and subtalar joint instability, as confirmed by clinical tests (positive anterior drawer and inversion stress tests) and radiographic imaging (positive subtalar stress radiographs).\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Furthermore, MRI findings of ligamentous damage in both the ATFL and CFL were essential for confirming the need for surgical intervention.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient Selection\u003c/h2\u003e \u003cp\u003eThe criteria included in our study were as follows: (1) Patients with CAI combined with STI who underwent arthroscopic treatment after failed non-surgical treatment, (2) Patients who completed a\u0026thinsp;\u0026ge;\u0026thinsp;2-year postoperative follow-up with complete clinical evaluation data.\u003c/p\u003e \u003cp\u003eThe exclusion criteria were as follows: (1) previous surgery of the affected limb, (2) lateral malleolar fracture on the affected side, (3) significant bone deformities in the affected ankle or foot, (4) poor ligament quality during surgery that was not suitable for repair, (5) chronic ankle osteoarthritis, (6) BMI\u0026thinsp;\u0026gt;\u0026thinsp;30, and (7) abnormalities of the interosseous talocalcaneal ligament (ITCL) and/or cervical ligament (CL) on MRI.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eGroup Division\u003c/h3\u003e\n\u003cp\u003ePatients were divided into two groups based on whether additional CFL repair was performed following arthroscopic ATFL repair for CLAI combined with STI: ATFL group underwent arthroscopic ATFL repair alone, while ATFL\u0026thinsp;+\u0026thinsp;CFL group underwent arthroscopic ATFL repair with additional CFL repair. Between January 2018 and June 2020, patients with CLAI combined with STI were treated exclusively with isolated arthroscopic ATFL repair. After July 2020, combined arthroscopic ATFL and CFL repair was adopted. The reason for this procedural change was concern that isolated ATFL repair might be insufficient to restore subtalar joint stability. To ensure subtalar joint stability and improve the long-term outcomes of surgery, the all-inside arthroscopic combined ATFL and CFL repair technique was used after July 2020.\u003c/p\u003e\n\u003ch3\u003eOperative Technique\u003c/h3\u003e\n\u003cp\u003eThe patient was positioned in the supine position, with an inflatable tourniquet applied to the proximal thigh for hemostasis. Three arthroscopic portals were marked on the skin. The P1 portal was located approximately 1 cm proximal to the ankle joint line and just lateral to the anterior tibial tendon. This portal served as the viewing portal. The P2 portal was located approximately 1 cm distal to the ankle joint line and just lateral to the peroneus tertius tendon. This portal was used as the working portal. The P3 portal was located at the tarsal sinus and could be used as both the working and the viewing portal (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Diagnostic arthroscopy was performed to debride the hyperplastic synovium and intra-articular scar tissue, and the concomitant lesions were treated at the same time.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eArthroscopic Anatomic ATFL Repair.\u003c/b\u003e Debridement of the ATFL footprint area of the lateral malleolus, a probe was used to explore and confirm the significant laxity of the ATFL (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). A 3.0-mm absorbable suture anchor (Smith \u0026amp; Nephew, London, UK) was inserted into the debrided ATFL footprint on the fibula using the P3 portal (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). The SutureLasso (Arthrex, Naples, FL) was inserted through the P3 portal from the lower lateral to the upper medial side of the ATFL (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). The wire loop was retrieved from the P3 portal with a grasper and passed through one suture. Then, the SutureLasso was withdrawn through the upper medial to the lower lateral direction, following the same approach. The wire loop of the SutureLasso pulled the thread of the suture out of the P3 portal from the midportion (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD). The end of the suture was passed through its own midportion to form a loop, then locked with a slip-knot technique (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eAdditional CFL Repair.\u003c/b\u003e After ATFL anatomic repair, switched to the P2 portal as the working portal and the P3 portal as the viewing portal, the tarsal sinus was debrided as well, exposing the distal joint, ITCL, and CL. The ITCL was identified as normal with the probe (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA), ruling out rotational instability of the subtalar joint. Dissection was then performed along the medial side of the peroneal tendons to expose the CFL. The probe was used to assess the integrity and relaxation of the CFL and the posterior articular surface of the subtalar joint, both of which were confirmed to be lax, further indicating subtalar instability (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB-C). A 3.0-mm absorbable suture anchor was inserted at the CFL footprint on the calcaneus (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD). The CFL was tightened using the same method as previously described (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eE-G).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient was immobilized in a neutral position with a short leg cast for 3\u0026ndash;4 weeks. Physical therapy and range of motion exercises were initiated 6 weeks postoperatively. Additionally, the patient engaged in ankle joint proprioceptive training for 2\u0026ndash;3 months.\u003c/p\u003e\n\u003ch3\u003eClinical Evaluations\u003c/h3\u003e\n\u003cp\u003eThe assessment of clinical outcomes included preoperative and during the final follow-up (at least 24 months postoperatively) evaluations using the Visual Analog Scale (VAS), American Orthopaedic Foot \u0026amp; Ankle Society Ankle-Hindfoot Scale (AOFAS-AH), and the Karlsson Ankle Functional Score (KAFS).\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eRadiographic Evaluations\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eStress Radiography.\u003c/b\u003e All patients underwent preoperative weight-bearing anteroposterior, lateral radiographs of the foot and ankle, as well as hindfoot alignment views to investigate the presence of malalignment.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Stress radiographs were recorded using a Telos device (Telos GmbH, Marburg, Germany) at both preoperative and final follow-up evaluations (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Standardized methods were used for all stress radiographs, measuring the talar tilt angle and anterior talar translation to assess ankle stability, as well as the subtalar tilt angle and calcaneal medial translation to evaluate subtalar joint stability. All measurements were conducted using a digital Neusoft PACS/RIS imaging system by two orthopedic surgeons, and the results were averaged for accuracy.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eMRI Scan.\u003c/b\u003e All patients were performed with a 1.5-T MRI scanner (Artoscan, Esca, Gscan) preoperatively and at the one-year postoperative follow-up to confirm ligament integrity (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The normal ATFL is identified as a linear, thin, low-signal-intensity band on T1-weighted axial images.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e The CFL is identified as a round, uniform, low-signal-intensity structure on cross-sectional images.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e According to the criteria proposed by Joshy et al.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e chronic ligament tears or dysfunction were diagnosed if the ligament appeared invisible, discontinuous, or had a wavy or curved contour. Ligaments showing uniform low-signal intensity on imaging were considered normal.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed using SPSS (version 22.0; SPSS Inc, Chicago, IL). The Shapiro-Wilk test was used to evaluate the normality of the data distribution. Continuous variables following a normal distribution were analyzed using an unpaired \u003cem\u003et\u003c/em\u003e-test, while the Mann-Whitney \u003cem\u003eU\u003c/em\u003e test was applied for variables that did not meet normality assumptions. Paired data were analyzed using a paired \u003cem\u003et\u003c/em\u003e-test or Wilcoxon signed-rank test as appropriate. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05 was considered indicative of statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom January 2018 to January 2022, 35 patients with CLAI combined with STI were treated with arthroscopic ligament repair surgery at our hospital.1 case were excluded due to ankle fractures; 2 case underwent ligament reconstruction surgery due to poor ligament quality observed during surgery; 1 case had osteoarthritis and osteochondritis; and 1 case had a follow-up period of less than two years. Eventually, a total of 30 patients were included in the study and divided into two groups based on whether additional CFL repair was performed under arthroscopy: the isolated ATFL repair group (n=14) and the ATFL + CFL repair group (n=16). The baseline characteristics of the patients between the two groups showed no significant differences (\u003cem\u003eP\u003c/em\u003e \u0026gt; .05, Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u003c/strong\u003e \u003cstrong\u003e1.\u003c/strong\u003e Demographic characteristics of the patients.\u003csup\u003ea.\u003c/sup\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003eDemographics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eATFL repair\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n= 14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eATFL + CFL repair (n= 16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003eAge, y, mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e33.4 \u0026plusmn; 6.3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e31.7 \u0026plusmn; 4.5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e.734\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003eSex: male, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e8 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e10 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e.626\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003eBMI, mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e23.2 \u0026plusmn; 2.3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e22.9 \u0026plusmn; 2.1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e.887\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003eSide: left, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e5 (55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e8 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e.854\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003eSymptom duration, mo, mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e25.4 \u0026plusmn; 3.8\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e27.8 \u0026plusmn; 4.2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e.768\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003eFollow-up, mo, mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e24.3 \u0026plusmn; 4.3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e24.5 \u0026plusmn; 3.9\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e.943\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003eConcomitant intra-articular lesions, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Osteochondral lesion\u003c/p\u003e\n \u003cp\u003eLoose body\u003c/p\u003e\n \u003cp\u003eOsteophytes\u003c/p\u003e\n \u003cp\u003eSubfibular ossicle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (21.4)\u003c/p\u003e\n \u003cp\u003e2 (14.2)\u003c/p\u003e\n \u003cp\u003e2 (14.3)\u003c/p\u003e\n \u003cp\u003e4 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (25.0)\u003c/p\u003e\n \u003cp\u003e3 (18.8)\u003c/p\u003e\n \u003cp\u003e4 (25.0)\u003c/p\u003e\n \u003cp\u003e5 (31.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.748\u003c/p\u003e\n \u003cp\u003e.629\u003c/p\u003e\n \u003cp\u003e.128\u003c/p\u003e\n \u003cp\u003e.726\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eCategorical variables are reported as n (%). Continuous variables are reported as mean \u0026plusmn; SD.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAbbreviations: BMI, body mass index.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe VAS scores, AOFAS-AH scores, and Karlsson-Peterson scores showed significant improvement at 12 months postoperatively and at the final follow-up in both groups compared to preoperative values (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; .01, Table 2). At 12 months, the ATFL + CFL repair group demonstrated significantly lower VAS scores (2.4 \u0026plusmn; 0.6 vs. 3.5 \u0026plusmn; 0.4) and higher AOFAS-AH scores (85.4 \u0026plusmn; 7.2 vs. 76.8 \u0026plusmn; 4.7) and Karlsson-Peterson scores (83.2 \u0026plusmn; 10.8 vs. 74.4 \u0026plusmn; 6.8) compared to the ATFL repair-only group (\u003cem\u003eP\u003c/em\u003e \u0026lt; .01). This trend persisted at the final follow-up, with the ATFL + CFL group showing superior VAS (2.2 \u0026plusmn; 0.4 vs. 2.8 \u0026plusmn; 0.7), AOFAS-AH (88.5 \u0026plusmn; 2.9 vs. 78.1 \u0026plusmn; 8.2), and Karlsson-Peterson scores (85.6 \u0026plusmn; 5.9 vs. 77.8 \u0026plusmn; 9.1) (\u003cem\u003eP\u003c/em\u003e \u0026lt; .01). These results indicate that although both groups achieved substantial improvements, the ATFL + CFL repair group consistently exhibited better pain relief and functional recovery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e Functional outcomes comparison of the two groups. \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"102%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eFunctional Outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003eATFL repair\u003c/p\u003e\n \u003cp\u003e(n=14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eATFL + CFL repair\u003c/p\u003e\n \u003cp\u003e(n=16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eVisual analog scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e6.4 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e6.7 \u0026plusmn; 2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e.354\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e12 mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e3.5 \u0026plusmn; 0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2.4 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eFinal follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e2.8 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2.2 \u0026plusmn; 0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value (preoperative vs 12 mo)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eKarlsson-Peterson scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e45.2 \u0026plusmn; 7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e42.1 \u0026plusmn; 8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e.673\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e12 mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e74.4 \u0026plusmn; 6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e83.2 \u0026plusmn; 10.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eFinal follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e77.8 \u0026plusmn; 9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e85.6 \u0026plusmn; 5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003evalue (preoperative vs 12 mo)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eAOFAS-AH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e55.3 \u0026plusmn; 7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e57.8 \u0026plusmn; 8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e.735\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e12 mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e76.8 \u0026plusmn; 4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e85.4 \u0026plusmn; 7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eFinal follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e78.1 \u0026plusmn; 8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e88.5 \u0026plusmn; 2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003evalue (preoperative vs 12 mo)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eContinuous variables are reported as mean\u0026nbsp;\u0026plusmn;\u0026nbsp;SD. Abbreviations:\u0026nbsp;AOFAS-AH,\u0026nbsp;American Orthopaedic Foot \u0026amp; Ankle Society Ankle-Hindfoot Scale\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRadiographic Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe radiological outcomes demonstrated significant improvements in both groups after surgical treatment (Table 3). Talar tilt angle (TTA), subtalar tilt angle (STA), and medial calcaneal translation (CMT) were significantly reduced at 12 months postoperatively and at the final follow-up compared to preoperative values (\u003cem\u003eP\u003c/em\u003e \u0026lt; .01). However, the ATFL + CFL repair group exhibited superior radiological outcomes compared to the ATFL repair-only group. At 12 months, the TTA was significantly lower in the ATFL + CFL group (4.4 \u0026plusmn; 0.9\u0026deg;) compared to the ATFL-only group (6.2 \u0026plusmn; 1.3\u0026deg;) (\u003cem\u003eP\u003c/em\u003e \u0026lt; .05), and this difference further widened at the final follow-up (4.3 \u0026plusmn; 0.6\u0026deg; vs. 6.7 \u0026plusmn; 0.7\u0026deg;, \u003cem\u003eP\u003c/em\u003e \u0026lt; .01). Similarly, the STA at 12 months was substantially reduced in the ATFL + CFL group (4.1 \u0026plusmn; 1.3\u0026deg;) compared to the ATFL-only group (7.8 \u0026plusmn; 1.7\u0026deg;, \u003cem\u003eP\u003c/em\u003e \u0026lt; .01), with this trend persisting at the final follow-up (4.2 \u0026plusmn; 2.1\u0026deg; vs. 8.1 \u0026plusmn; 2.2\u0026deg;, \u003cem\u003eP\u003c/em\u003e \u0026lt; .01). Moreover, the CMT was markedly lower in the ATFL + CFL group (2.7 \u0026plusmn; 1.4 mm) at 12 months compared to the ATFL-only group (5.8 \u0026plusmn; 2.7 mm,\u003cem\u003e\u0026nbsp;P\u003c/em\u003e \u0026lt; .01), and this significant difference remained at the final follow-up (2.7 \u0026plusmn; 0.8 mm vs. 6.1 \u0026plusmn; 2.5 mm, \u003cem\u003eP\u003c/em\u003e \u0026lt; .01). There was no statistically significant difference in the anterior talar translation (ATT) in two groups at any time point (\u003cem\u003eP\u003c/em\u003e \u0026gt; .05). At the one-year postoperative follow-up, MRI scans demonstrated successful ligament healing in both groups. The ATFL was visualized as a well-defined, linear structure with low signal intensity on T1-weighted axial images, while the CFL appeared as a consistent, rounded, low-signal-intensity band in cross-sectional views\u0026nbsp;(Figures 5C-D).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Radiological outcomes comparison of the two groups.\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"102%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eRadiological Outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003eATFL repair\u003c/p\u003e\n \u003cp\u003e(n=14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eATFL + CFL repair\u003c/p\u003e\n \u003cp\u003e(n=16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eTalar tilt angle, degrees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e12.3 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e11.9 \u0026plusmn; 3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e.734\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e12 mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e6.2 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e4.4 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eFinal follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e6.7 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e4.3 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value (preoperative vs 12 mo)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eAnterior talar translation, mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e11.8 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e12.0 \u0026plusmn; 0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e.875\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e12 mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e5.3 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e5.4 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e.641\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eFinal follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e5.4 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e5.3 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e.548\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003evalue (preoperative vs 12 mo)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eSubtalar tilt angle,\u0026nbsp;degrees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e11.3 \u0026plusmn; 2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e11.5 \u0026plusmn; 2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e.735\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e12 mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e7.8 \u0026plusmn; 1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e4.1 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eFinal follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e8.1 \u0026plusmn; 2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e4.2 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003evalue (preoperative vs 12 mo)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eMedial calcaneal translation, mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e9.3 \u0026plusmn; 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e9.1 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e.817\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e12 mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e5.8 \u0026plusmn; 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2.7 \u0026plusmn; 1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eFinal follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e6.1 \u0026plusmn; 2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2.7 \u0026plusmn; 0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003evalue (preoperative vs 12 mo)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eContinuous variables are reported as mean\u0026nbsp;\u0026plusmn;\u0026nbsp;SD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecurrence and Other Complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients had no incision-related complications, no nerve damage. However, at the final follow-up, 3 cases of recurrent instability with increased pain symptoms occurred in the isolated ATFL repair group, which later underwent ligament reconstruction surgery. No cases of recurrent instability were observed in the combined ATFL and CFL repair group.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe most important finding of this study is that the combined arthroscopic repair of the ATFL and CFL yielded superior clinical and radiological outcomes compared to isolated ATFL repair in patients with CLAI accompanied by STI. This study demonstrated the importance of addressing subtalar instability in the surgical management of these patients. Failure to adequately treat combined instability of the ankle and subtalar joints may lead to recurrent sprains and hinder optimal functional recovery.\u003c/p\u003e \u003cp\u003eThere are many studies that have shown that subtalar instability is often associated with combined injuries to the ITCL, CL, and CFL, while isolated ligament injuries are less common.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e However, in clinical practice, we have observed a number of cases where STI was caused by isolated CFL injuries. We hypothesize that this may be primarily due to the CFL being the first ligamentous structure injured during the development of subtalar instability, while the ITCL and CL are not yet significantly impacted in the early stages of the condition.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e The combined failure of the CFL and the ATFL can cause lateral ankle instability in conjunction with subtalar instability.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCurrently, there is no established method for diagnosing combined lateral instability of the ankle and subtalar joints. In our study, we diagnosed this condition through a comprehensive evaluation using clinical, radiographic, and arthroscopic assessments. First, we performed the anterior drawer and subtalar stress tests for a preliminary assessment. MRI subsequently confirmed injuries to both the ATFL and CFL, while the intrinsic ligaments of the subtalar joint were observed integrity. Initial assessment suggested the potential presence of combined lateral instability of the ankle and subtalar joints. Second, we used stress radiographs to assess lateral ankle instability by measuring anterior talar translation and the talar tilt angle.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e According to the diagnostic criteria proposed by Jung et al.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e for assessing lateral subtalar instability, we measured the subtalar tilt angle and calcaneal medial translation. Furthermore, we considered lateral laxation or opening of the subtalar joint was more significant than anterior translation of the calcaneus relative to the talus, since the intrinsic ligaments of the subtalar joint appeared normal and the medial deltoid ligament restricted anteroposterior movement.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Finally, intraoperative arthroscopy was used to definitively diagnose the lateral instability of the ankle and subtalar joints.\u003c/p\u003e \u003cp\u003eAnother important criterion we included was the positive findings of lateral subtalar instability under C-arm fluoroscopic subtalar stress views.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Before the formal surgery, we routinely performed subtalar stress tests under anesthesia using C-arm fluoroscopy. We considered continuous fluoroscopic imaging under anesthesia as a reliable method for diagnosing subtalar instability.\u003c/p\u003e \u003cp\u003eStudies have highlighted the CFL's role in subtalar joint stability. Li et al.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e reported that sectioning the CFL increases subtalar inversion during dorsiflexion, while Weindel et al.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e found it causes excessive joint motion, leading to instability. Kamada et al.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e further demonstrated that CFL repair can restore subtalar stability and alleviate symptoms. These findings align with our results, emphasizing the necessity of CFL repair to address subtalar instability in CLAI patients.\u003c/p\u003e \u003cp\u003eIn this study, we observed that ATFL repair alone improved ankle joint stability but failed to fully restore subtalar joint stability, as indicated by residual subtalar tilt angle and medial calcaneal translation. However, adding CFL repair significantly improved these radiological parameters, confirming the importance of addressing STI through additional CFL repair, further confirmed our hypothesis.\u003c/p\u003e \u003cp\u003eThere are few reports on the treatment of CLAI combined with STI. Lui et al.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e described a technique for arthroscopic anatomical reconstruction of the ATFL and CFL to treat STI combined with CLAI, which helps reconstruct the stability of the ankle and subtalar joints. Choisne et al.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e conducted simulations by sectioning and subsequently repairing key ligament structures on specimens. which significantly reduced subtalar and ankle inversion as well as subtalar internal rotation compared to the unstable condition. However, these studies are limited to technical and anatomical findings without clinical outcomes. This study is one of the first to comprehensively evaluate clinical and radiographic outcomes of arthroscopic ATFL and CFL repair in CLAI patients with STI. Postoperatively, both groups showed significant improvement in functional outcomes, but the ATFL\u0026thinsp;+\u0026thinsp;CFL group consistently outperformed the ATFL group in terms of pain relief and joint stability.\u003c/p\u003e \u003cp\u003eThere were several limitations in this study. First, the preoperative diagnosis of STI remains challenging due to its reliance on stress radiographs, MRI, and intraoperative findings, which require expertise and may not be universally available. Second, the retrospective design and relatively small sample size limit the generalizability of the findings. Future studies with larger cohorts and prospective designs are needed to validate these results. Third, the follow-up period was brief, potentially affecting the long-term validity of the results. Finally, the study did not include cases involving other critical ligaments of the subtalar joint, such as the ITCL and CL. If these ligaments are injured, repairing the CFL alone may be insufficient to restore subtalar joint stability.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e Further comprehensive research is required to address these limitations and enhance our understanding of effective treatments for instability of the ankle and subtalar joints.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe combined arthroscopic repair of the ATFL and CFL provides superior clinical and radiographic outcomes compared to isolated ATFL repair in managing CLAI with STI. This approach effectively restores stability in both the ankle and subtalar joints, improves functional recovery, and reduces pain. CFL repair should be considered in surgical planning to optimize outcomes and minimize the risk of recurrent instability.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of the Second Affiliated Hospital of Soochow University (JD-HG-2024-082), and all patients provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all the patients in this study for the article to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is supported by the Open Research Fund of the State Key Laboratory of Biotherapy, grant NO. (SKLB202409); the Project of Suzhou Sports Bureau, grant NO. (TY2024-103); the Project of State Key Laboratory of Radiation Medicine and Protection, Soochow University, grant NO. (GZK1202303); the Project of Second Affiliated Hospital of Soochow University \u0026apos;Resident Standardized Training Capacity Building Support Program\u0026apos;, grant NO. (ZPTJ-TD202405); the Project of 2023 \u0026apos;Four-Party Co-Construction\u0026apos; Special Project on Education and Teaching Reform of Suzhou Medical College, grant NO. (MX12301923).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMWW, JZG and LW contributed equally to this work and should be considered co-first authors. ZY collected and analysed the data. KWQ performed and analyzed the experiments. WY conceived and coordinated the study, designed. QJZ conceived and supervised the work, and wrote the paper. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Department of Hand and Foot Surgery, the Second Affiliated Hospital of Soochow University, Suzhou, China.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003eDepartment of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, China.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003e Suzhou Medical College, Soochow University, Suzhou, China.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003e Department of Wound Center, the Second Affiliated Hospital of Soochow University, Suzhou, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBridgman SA, Clement D, Downing A, Walley G, Phair I, Maffulli N. Population based epidemiology of ankle sprains attending accident and emergency units in the West Midlands of England, and a survey of UK practice for severe ankle sprains. \u003cem\u003eEmergency medicine journal : EMJ\u003c/em\u003e. Nov 2003;20(6):508-10. doi:10.1136/emj.20.6.508\u003c/li\u003e\n\u003cli\u003ede Azevedo Sodr\u0026eacute; Silva A, Sassi LB, Martins TB, et al. Epidemiology of injuries in young volleyball athletes: a systematic review. \u003cem\u003eJournal of orthopaedic surgery and research\u003c/em\u003e. Oct 4 2023;18(1):748. doi:10.1186/s13018-023-04224-3\u003c/li\u003e\n\u003cli\u003eXiao S, Shen B, Xu Z, et al. Balance Control Deficits are Associated With Diminished Ankle Force Sense, Not Position Sense, in Athletes With Chronic Ankle Instability. \u003cem\u003eArchives of physical medicine and rehabilitation\u003c/em\u003e. Nov 2024;105(11):2127-2134. doi:10.1016/j.apmr.2024.06.019\u003c/li\u003e\n\u003cli\u003eFerran NA, Maffulli N. 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Dec 14 2024:10711007241293780. doi:10.1177/10711007241293780\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"subtalar instability, chronic lateral ankle instability, anterior talofibular ligament, calcaneofibular ligament, arthroscopic","lastPublishedDoi":"10.21203/rs.3.rs-5886666/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5886666/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChronic lateral ankle instability (CLAI) is a common condition often associated with damage to the anterior talofibular ligament (ATFL). In cases where CLAI is accompanied by subtalar instability (STI) due to calcaneofibular ligament (CFL) injury, the optimal surgical approach remains controversial. While isolated ATFL repair has been shown to effectively restore ankle joint stability, it may be insufficient to address the subtalar joint instability caused by CFL damage. This study aimed to evaluate the clinical importance of CFL repair by comparing the outcomes of isolated ATFL repair versus combined ATFL and CFL repair.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective cohort study was conducted involving patients diagnosed with CLAI in conjunction with STI from January 2018 to January 2022. Participants were divided into two groups: one underwent isolated ATFL repair (ATFL group), and the other underwent combined ATFL and CFL repair (ATFL\u0026thinsp;+\u0026thinsp;CFL group). Clinical outcomes were assessed using the American Orthopaedic Foot \u0026amp; Ankle Society Ankle-Hindfoot Scale (AOFAS-AH), Karlsson Ankle Functional Score (KAFS) and Visual Analog Scale (VAS) scores, while radiological outcomes were evaluated by MRI and stress radiographs.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll the functional scores significantly improved in both groups post-surgery. However, the ATFL\u0026thinsp;+\u0026thinsp;CFL group demonstrated superior functional recovery, with higher AOFAS scores and greater reductions in VAS pain scores compared to the ATFL group. Radiological evaluation indicated better restoration of subtalar joint stability in the ATFL\u0026thinsp;+\u0026thinsp;CFL group. At the final follow-up, 3 cases of recurrent instability were observed in the isolated ATFL repair group. No significant difference in other complication rates was observed between the two groups.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe study demonstrated the importance of CFL repair in patients with CLAI in conjunction with STI. While isolated ATFL repair is effective for ankle joint stability, combined ATFL and CFL repair offers superior outcomes by addressing both ankle and subtalar joint instability. These findings suggest that CFL repair should be considered in surgical planning for patients with STI to optimize functional recovery and long-term stability.\u003c/p\u003e\u003ch2\u003eLevel of Evidence\u003c/h2\u003e \u003cp\u003eLevel III.\u003c/p\u003e","manuscriptTitle":"All-inside Arthroscopic Repair of ATFL and CFL Separately for Chronic Lateral Ankle Instability in Conjunction with Subtalar Instability","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-25 10:11:36","doi":"10.21203/rs.3.rs-5886666/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-27T07:32:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-27T02:57:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"264582338755614524606547616450557046276","date":"2025-03-24T19:02:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-24T12:23:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-24T05:51:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2025-03-24T04:51:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"303dd39d-e593-483a-9bbc-820d6d6fb03f","owner":[],"postedDate":"March 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-21T16:03:47+00:00","versionOfRecord":{"articleIdentity":"rs-5886666","link":"https://doi.org/10.1186/s13018-025-05780-6","journal":{"identity":"journal-of-orthopaedic-surgery-and-research","isVorOnly":false,"title":"Journal of Orthopaedic Surgery and Research"},"publishedOn":"2025-04-15 15:57:38","publishedOnDateReadable":"April 15th, 2025"},"versionCreatedAt":"2025-03-25 10:11:36","video":"","vorDoi":"10.1186/s13018-025-05780-6","vorDoiUrl":"https://doi.org/10.1186/s13018-025-05780-6","workflowStages":[]},"version":"v1","identity":"rs-5886666","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5886666","identity":"rs-5886666","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}