Two portals are sufficient for all-inside arthroscopic isolate anterior talofibular ligament repair

Abstract

Purpose: All-inside arthroscopic repair of the anterior talofibular ligament (ATFL) using two or three portals is one of the most commonly performed procedures for managing chronic lateral ankle instability (CLAI). However, it remains unclear whether there are differences in functional outcomes between the use of two versus three portals.

Methods: This retrospective comparative study included 66 patients with CLAI who underwent an all-inside arthroscopic isolated ATFL repair procedure between 2018 and 2021. Patients were divided into two groups according to the number of portals introduced. In the two-portal group (n = 31), the ATFL was repaired using two portals. In the three-portal group (n = 35), the ATFL was repaired using three portals. The American Orthopedic Foot and Ankle Society (AOFAS) scores, Karlsson Ankle Function Score (KAFS), Anterior Talar Translation (ATT), Active Joint Position Sense (AJPS), complications, as well as the time of return to sports were compared between the two groups.

Results: All patients were followed up for a minimum of 2 years. Improvement in functional outcomes (AOFAS, KAFS, ATT and AJPS) was recorded at the final follow-up. No significant differences were observed between the two groups in terms of operative time, AOFAS, KAFS, ATT, AJPS, or the time of return to sports. However, no nerve complications were observed in the two-portal group.

Conclusion: In patients with CLAI undergoing all-inside arthroscopic isolate ATFL repair, the use of either two or three portals results in comparable and favorable functional outcomes. The two-portal procedure was also associated with no superficial peroneal nerve injuries.

Level of evidence: Level III.

Keywords: Arthroscopic ATFL repair; Chronic lateral ankle instability; Portal.

Fig. 1

Arthroscopic portals of the anterior ankle

Fig. 2

Combined images of external portal intervention (A) and intra-articular arthroscopic views (B)

Fig. 3

Technique of two-portal all-inside arthroscopic anterior talofibular ligament repair in the left ankle. A chronic lateral ankle instability confirmed at the magnetic resonance imaging; B The anterior talofibular ligament was detached from the distal fibula; C A single-loaded suture anchor was inserted into the mid-portion of the fibular footprint; D, E The anterior talofibular ligament was sutured in a loop configuration; F Overview of the two portals

Fig. 4

AOFAS score of the two groups

Fig. 5

KAFS score of the two groups

Fig. 6

AJPS score of the two groups