Practice Guideline

. 2025 Apr 4;154(1):ldaf001.

doi: 10.1093/bmb/ldaf001.

All-inside arthroscopic procedures for chronic lateral ankle instability: evidence-based clinical practice guidelines

Shi-Ming Feng¹, Nicola Maffulli^{2

3

4}, C Niek van Dijk^{5

6

7

8}, Hai-Lin Xu⁹, Kai Fehske^{10

11}, Christian Plaass¹², Francesco Oliva¹³, Thomas Karius¹¹, Shun-Hong Gao¹⁴, Wei Xu¹⁵, Lu Bai¹⁶, Run-Lai Song¹⁷, Yue-Feng Hao¹⁸, Hui Zhang¹⁹, Yang-Bo Xu²⁰, Ning Zhang²¹, Lei Lou²², Tian-Tian Ren²³, Guo-Dong Wang²⁴, Qi Li²⁵, Jian-Hua Wu²⁶, Yong-Zhan Zhu²⁷, Gang Yin²⁸, Tong-Fu Wang²⁹, Jian-Zhong Qin³⁰, Amol Saxena³¹, Chao Ma¹

Affiliations

¹ Sports Medicine Department, Xuzhou Central Hospital, Xuzhou Clinical College of Xuzhou Medical University, NO.199 Jiefang South Road, Quanshan district, Xuzhou 221009, PR China.
² Department of Orthopaedics and Traumatology, University La Sapienza, Faculty of Medicine and Psychology, Via di Grottarossa, 00189, Rome, Italy.
³ Guy Hilton Research Centre, School of Pharmacy and Bioengineering, Keele University, Thornburrow Drive, Stoke-on-Trent ST4 7QB, United Kingdom.
⁴ Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, United Kingdom.
⁵ Department of Orthopedic Surgery, University of Amsterdam, Meibergdreef 9, Amsterdam, 1081 HV, The Netherlands.
⁶ Ankle Unit, FIFA Medical Centre of Excellence Ripoll-DePrado Sport Clinic, C. de Almagro, 34, Chamberí, Madrid 28010, Spain.
⁷ Ankle Unit, FIFA Medical Centre of Excellence Clínica do Dragão, Estádio Dragão Entrada Nascente, Porto 4350-415, Portugal.
⁸ Casa di Cura, San Rossore, Viale delle Cascine, 152/f, Pisa 56122, Italy.
⁹ Department of Trauma and Orthopedic, People's Hospital, Peking University, No. 11 Xizhimen South Street, Xicheng District, Beijing 100044, PR China.
¹⁰ Department of Trauma Surgery, University Hospital Wuerzburg, Josef-Schneider-Straße 2, Wuerzburg 97080, Germany.
¹¹ Department of Orthopedic and Trauma Surgery, Johanniter Waldkrankenhaus Bonn, Waldstraße 73, Bonn 53177, Germany.
¹² Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Strasse 1-7, Hannover 30625, Germany.
¹³ Department of Sports Traumatology, Universita' Telematica San Raffaele, Via di Val Cannuta, 247 Roma, Italy.
¹⁴ Orthopaedic Department, The Second Hospital of Tangshan, No. 21, North Jianshe Road, Lubei District, Tangshan 063000, PR China.
¹⁵ Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, No. 1055, Sanxiang Road, Gusu District, Suzhou 215004, PR China.
¹⁶ Department of Orthopaedics, Peking University Shenzhen Hospital, No. 1120, Lianhua Road, Futian District, Shenzhen 518035, PR China.
¹⁷ Orthopedic Medical Center, Yibin Second People's Hospital, No. 96 Beida Street, Cuiping District, YiBin 644000, China.
¹⁸ Orthopedics and Sports Medicine Center, Suzhou Municipal Hospital, Nanjing Medical University Affiliated Suzhou Hospital, No. 242, Guangji Road, Gusu District, Suzhou 215008, PR China.
¹⁹ Department of Orthopedics and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu 610041, China.
²⁰ Department of Bone and Joint Surgery, Affiliated Hospital of Southwest Medical University, No. 8, Section 2, Kangcheng Road, Jiangyang District, Luzhou 646099, PR China.
²¹ Department of Foot and Ankle Surgery, The Second Hospital of Shandong University, 247 Beiyuan Street, Tianqiao District, Jinan 250033, PR China.
²² Department of Orthopaedics, Luoyang Orthopedic-Traumatological Hospital of Henan Province, No. 82, Qiming South Road, Chanhe Hui District, Luoyang 471002, PR China.
²³ Department of Orthopaedics, The First Affiliated Hospital of Ningbo University, No. 59 Liuting Street, Haishu District, Ningbo 315000, PR China.
²⁴ Department of Orthopaedics, Affiliated Hospital of Jining Medical University, No. 89 Guhuai Road, Rencheng District, Jining City 272000, PR China.
²⁵ Sports Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu 610041, China.
²⁶ Department of Trauma Orthopedics, The Affiliated Hospital of Guizhou Medical University, No. 28, Guiyi Street, Yunyan District, Guiyang 550004, China.
²⁷ Department of Orthopedics, Foshan Hospital of Traditional Chinese Medicine, No. 6, Qinren Road, Chancheng District, Foshan 528000, China.
²⁸ Department of Orthopedics, Binzhou Medical University Hospital, No. 661, Huanghe 2nd Road, Bincheng District, Binzhou 256603, China.
²⁹ Department of Sports Medicine and Arthroscopy, Tianjin Hospital of Tianjin University, No. 406, Jiefang South Road, Hexi District, Tianjin 300211, China.
³⁰ Department of Hand and Foot, The Second Affiliated Hospital of Soochow University, No. 1055, Sanxiang Road, Gusu District, Suzhou 215004, PR China.
³¹ Department of Sports Medicine, Sutter-PAMF, 795 El Camino Real, Palo Alto, CA 94301, United States.

PMID: 40183802
PMCID: PMC11970022
DOI: 10.1093/bmb/ldaf001

Practice Guideline

All-inside arthroscopic procedures for chronic lateral ankle instability: evidence-based clinical practice guidelines

Shi-Ming Feng et al. Br Med Bull. 2025.

. 2025 Apr 4;154(1):ldaf001.

doi: 10.1093/bmb/ldaf001.

Authors

Affiliations

¹ Sports Medicine Department, Xuzhou Central Hospital, Xuzhou Clinical College of Xuzhou Medical University, NO.199 Jiefang South Road, Quanshan district, Xuzhou 221009, PR China.
² Department of Orthopaedics and Traumatology, University La Sapienza, Faculty of Medicine and Psychology, Via di Grottarossa, 00189, Rome, Italy.
³ Guy Hilton Research Centre, School of Pharmacy and Bioengineering, Keele University, Thornburrow Drive, Stoke-on-Trent ST4 7QB, United Kingdom.
⁴ Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, United Kingdom.
⁵ Department of Orthopedic Surgery, University of Amsterdam, Meibergdreef 9, Amsterdam, 1081 HV, The Netherlands.
⁶ Ankle Unit, FIFA Medical Centre of Excellence Ripoll-DePrado Sport Clinic, C. de Almagro, 34, Chamberí, Madrid 28010, Spain.
⁷ Ankle Unit, FIFA Medical Centre of Excellence Clínica do Dragão, Estádio Dragão Entrada Nascente, Porto 4350-415, Portugal.
⁸ Casa di Cura, San Rossore, Viale delle Cascine, 152/f, Pisa 56122, Italy.
⁹ Department of Trauma and Orthopedic, People's Hospital, Peking University, No. 11 Xizhimen South Street, Xicheng District, Beijing 100044, PR China.
¹⁰ Department of Trauma Surgery, University Hospital Wuerzburg, Josef-Schneider-Straße 2, Wuerzburg 97080, Germany.
¹¹ Department of Orthopedic and Trauma Surgery, Johanniter Waldkrankenhaus Bonn, Waldstraße 73, Bonn 53177, Germany.
¹² Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Strasse 1-7, Hannover 30625, Germany.
¹³ Department of Sports Traumatology, Universita' Telematica San Raffaele, Via di Val Cannuta, 247 Roma, Italy.
¹⁴ Orthopaedic Department, The Second Hospital of Tangshan, No. 21, North Jianshe Road, Lubei District, Tangshan 063000, PR China.
¹⁵ Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, No. 1055, Sanxiang Road, Gusu District, Suzhou 215004, PR China.
¹⁶ Department of Orthopaedics, Peking University Shenzhen Hospital, No. 1120, Lianhua Road, Futian District, Shenzhen 518035, PR China.
¹⁷ Orthopedic Medical Center, Yibin Second People's Hospital, No. 96 Beida Street, Cuiping District, YiBin 644000, China.
¹⁸ Orthopedics and Sports Medicine Center, Suzhou Municipal Hospital, Nanjing Medical University Affiliated Suzhou Hospital, No. 242, Guangji Road, Gusu District, Suzhou 215008, PR China.
¹⁹ Department of Orthopedics and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu 610041, China.
²⁰ Department of Bone and Joint Surgery, Affiliated Hospital of Southwest Medical University, No. 8, Section 2, Kangcheng Road, Jiangyang District, Luzhou 646099, PR China.
²¹ Department of Foot and Ankle Surgery, The Second Hospital of Shandong University, 247 Beiyuan Street, Tianqiao District, Jinan 250033, PR China.
²² Department of Orthopaedics, Luoyang Orthopedic-Traumatological Hospital of Henan Province, No. 82, Qiming South Road, Chanhe Hui District, Luoyang 471002, PR China.
²³ Department of Orthopaedics, The First Affiliated Hospital of Ningbo University, No. 59 Liuting Street, Haishu District, Ningbo 315000, PR China.
²⁴ Department of Orthopaedics, Affiliated Hospital of Jining Medical University, No. 89 Guhuai Road, Rencheng District, Jining City 272000, PR China.
²⁵ Sports Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu 610041, China.
²⁶ Department of Trauma Orthopedics, The Affiliated Hospital of Guizhou Medical University, No. 28, Guiyi Street, Yunyan District, Guiyang 550004, China.
²⁷ Department of Orthopedics, Foshan Hospital of Traditional Chinese Medicine, No. 6, Qinren Road, Chancheng District, Foshan 528000, China.
²⁸ Department of Orthopedics, Binzhou Medical University Hospital, No. 661, Huanghe 2nd Road, Bincheng District, Binzhou 256603, China.
²⁹ Department of Sports Medicine and Arthroscopy, Tianjin Hospital of Tianjin University, No. 406, Jiefang South Road, Hexi District, Tianjin 300211, China.
³⁰ Department of Hand and Foot, The Second Affiliated Hospital of Soochow University, No. 1055, Sanxiang Road, Gusu District, Suzhou 215004, PR China.
³¹ Department of Sports Medicine, Sutter-PAMF, 795 El Camino Real, Palo Alto, CA 94301, United States.

PMID: 40183802
PMCID: PMC11970022
DOI: 10.1093/bmb/ldaf001

Abstract

Background: All-inside arthroscopic procedures are now frequently employed to manage chronic lateral ankle instability (CLAI) with satisfactory functional outcomes. Currently, no evidence-based guidelines exist for all-inside arthroscopic procedures for CLAI. Many surgical decisions remain uncertain and challenging.

Sources of data: Published scientific literature in PubMed, MEDLINE, Web of Science, EMBASE, and Cochrane databases.

Areas of agreement: All-inside arthroscopic repair and reconstruction procedures are reliable treatments for CLAI.

Areas of controversy: The all-inside arthroscopic procedures for CLAI present significant challenges, particularly in the following aspects.

Growing points: Given the lack of guidelines for the all-inside arthroscopic procedures for CLAI, this evidence-based clinical practice guideline provides 11 recommendations to address the controversy.

Areas timely for developing research: In patients with CLAI undergoing all-inside arthroscopic procedures, comparative studies are urgently needed to establish the optimal timing for weight-bearing, as well as return to work and sports.

Keywords: arthroscopic management; chronic lateral ankle instability; guidelines.

PubMed Disclaimer

Conflict of interest statement

None declared.

Figures

**Figure 1**
Flowchart of the literature search.

**Figure 2**
Suture configurations. (A) Loop suture configuration. (B) Free-edge suture configuration. (C) Horizontal mattress suture.

**Figure 3**
Ligament remnant preservation reconstruction.

**Figure 4**
Repair of the remnant of the ligament with augmentation (Broström–Gould).

**Figure 5**
(A) Anatomic reconstruction procedure. (B) Broström repair procedure.

See this image and copyright information in PMC

Cited by

Two portals are sufficient for all-inside arthroscopic isolate anterior talofibular ligament repair.
Feng SM, Xue Y, Zhang ZH, Xue C, Gao SH. Feng SM, et al. Arch Orthop Trauma Surg. 2025 May 24;145(1):316. doi: 10.1007/s00402-025-05927-4. Arch Orthop Trauma Surg. 2025. PMID: 40413275 Free PMC article.

References

1. Kim SH, Lee SH, Kim JY, et al. Comparison of midterm outcomes between all-inside arthroscopic and open modified Broström procedures as treatment for chronic ankle instability. Clin Orthop Surg 2024;16:628–35. 10.4055/cios23108. - DOI - PMC - PubMed
1. Lee SH, Yang JH, Kim I. Nonanatomic all-inside arthroscopic anterior talofibular ligament repair with a high-position anchor versus anatomic repair: an analysis based on 3D CT. Am J Sports Med 2022;50:2134–44. 10.1177/03635465221097119. - DOI - PubMed
1. Lee SH, Cho HG, Yang JH. Additional inferior extensor retinaculum augmentation after all-inside arthroscopic anterior talofibular ligament repair for chronic ankle instability is not necessary. Am J Sports Med 2021;49:1721–31. 10.1177/03635465211008097. - DOI - PubMed
1. Guelfi M, Nunes GA, Malagelada F, et al. Arthroscopic-assisted versus all-arthroscopic ankle stabilization technique. Foot Ankle Int 2020;41:1360–7. 10.1177/1071100720938672. - DOI - PubMed
1. Mirza K, Menezes RJ, Acharya PU, et al. Donor-site morbidity following arthroscopic anterior cruciate ligament reconstruction using peroneus longus tendon autograft. Eur J Orthop Surg Traumatol 2024;34:3171–80. 10.1007/s00590-024-04046-x. - DOI - PubMed

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All-inside arthroscopic procedures for chronic lateral ankle instability: evidence-based clinical practice guidelines

Affiliations

All-inside arthroscopic procedures for chronic lateral ankle instability: evidence-based clinical practice guidelines

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Abstract

Conflict of interest statement

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