Skip to main content

Repair of only anterior talofibular ligament resulted in similar outcomes to those of repair of both anterior talofibular and calcaneofibular ligaments



To compare the surgical outcomes of the two different ankle stabilization techniques.


This randomized controlled trial aimed to compare the outcomes of the modified Broström procedure with [calcaneofibular ligament (CFL) group] or without CFL repair [anterior talofibular ligament (ATFL) only group]. Of the 50 patients randomly assigned to two groups, 43 were followed up prospectively for ≥ 2 years (CFL group: 22 patients, 36.6 ± 13.1 months; ATFL Only group: 21 patients, 35.3 ± 11.9 months). Functional outcomes were assessed using the Karlsson–Peterson and Tegner activity level scoring systems. Anterior talar translation (ATT), talar tilt angle (TTA), and degrees of displacement of the calcaneus against the talus on stress radiographs were measured. All parameters were compared between the two groups. Multiple regression analysis setting the postoperative Karlsson–Peterson score as the dependent variable was performed to determine the significant variable.


There were no significant differences between the two groups in functional (Karlsson–Peterson and Tegner activity level) scores at the last follow-up and their changes. There were no significant differences between the two groups in the ATT, TTA, their differences compared with the contralateral ankles, and degrees of displacement of the calcaneus against the talus at the last follow-up. Osteochondral lesion of the talus rather than CFL repair was the significant variable related to functional outcome.


The modified Broström procedure with additional CFL repair did not result in a significant advantage in any measured outcome at 3 years.

Level of evidence

Randomized controlled trial, Level I.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2


  1. Ahn JH, Lee Y-G, Jung S-H, Choy W-S (2007) Treatment of chronic ankle lateral instability using modified Brostrom procedure. J Korean Orthop Assoc 42:91–97

    Article  Google Scholar 

  2. Beighton P, Solomon L, Soskolne CL (1973) Articular mobility in an African population. Ann Rheum Dis 32:413–418

    Article  CAS  Google Scholar 

  3. Bell SJ, Mologne TS, Sitler DF, Cox JS (2006) Twenty-six-year results after Brostrom procedure for chronic lateral ankle instability. Am J Sports Med 34:975–978

    Article  Google Scholar 

  4. Breitenseher MJ, Trattnig S, Kukla C, Gaebler C, Kaider A, Baldt MM, Haller J, Imhof H (1997) MRI versus lateral stress radiography in acute lateral ankle ligament injuries. J Comput Assist Tomogr 21:280–285

    Article  CAS  Google Scholar 

  5. Broström L (1966) Sprained ankles. V. Treatment and prognosis in recent ligament ruptures. Acta Chir Scand 132:537–550

    PubMed  Google Scholar 

  6. Choi WJ, Lee JW, Han SH, Kim BS, Lee SK (2008) Chronic lateral ankle instability: the effect of intra-articular lesions on clinical outcome. Am J Sports Med 36:2167–2172

    Article  Google Scholar 

  7. Dalmau-Pastor M, Yasui Y, Calder JD, Karlsson J, Kerkhoffs GM, Kennedy JG (2016) Anatomy of the inferior extensor retinaculum and its role in lateral ankle ligament reconstruction: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 24:957–962

    Article  CAS  Google Scholar 

  8. De Vries J, Struijs PA, Raaymakers EL, Marti RK (2005) Long-term results of the Weber operation for chronic ankle instability: 37 patients followed for 20–30 years. Acta Orthop 76:891–898

    Article  Google Scholar 

  9. Doherty C, Delahunt E, Caulfield B, Hertel J, Ryan J, Bleakley C (2014) The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies. Sports Med 44:123–140

    Article  Google Scholar 

  10. Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC (1998) Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int 19:653–660

    Article  CAS  Google Scholar 

  11. Gould N, Seligson D, Gassman J (1980) Early and late repair of lateral ligament of the ankle. Foot Ankle 1:84–89

    Article  CAS  Google Scholar 

  12. Grace DL (1984) Lateral ankle ligament injuries. Inversion and anterior stress radiography. Clin Orthop Relat Res 183:153–159

    Google Scholar 

  13. Jung HG, Park JT, Shin MH, Lee SH, Eom JS, Lee DO (2015) Outcome of subtalar instability reconstruction using the semitendinosus allograft tendon and biotenodesis screws. Knee Surg Sports Traumatol Arthrosc 23:2376–2383

    Article  Google Scholar 

  14. Karlsson J, Bergsten T, Lansinger O, Peterson L (1988) Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Jt Surg Am 70:581–588

    Article  CAS  Google Scholar 

  15. Karlsson J, Eriksson BI, Swärd L (1996) Early functional treatment for acute ligament injuries of the ankle joint. Scand J Med Sci Sports 6:341–345

    Article  CAS  Google Scholar 

  16. Karlsson J, Petersen L (1991) Evaluation of ankle function: the use of a scoring scale. Foot 1:15–19

    Article  Google Scholar 

  17. Kato T (1995) The diagnosis and treatment of instability of the subtalar joint. J Bone Jt Surg Br 77:400–406

    Article  CAS  Google Scholar 

  18. Kobayashi T, Yamakawa S, Watanabe K, Kimura K, Suzuki D, Otsubo H, Teramoto A, Fujimiya M, Fujie H, Yamashita T (2016) The in situ force in the calcaneofibular ligament and the contribution of this ligament to ankle joint stability. Clin Biomech (Bristol Avon) 40:8–13

    Article  Google Scholar 

  19. Lee KT, Lee JI, Sung KS, Kim JY, Kim ES, Lee SH, Wang JH (2008) Biomechanical evaluation against calcaneofibular ligament repair in the Brostrom procedure: a cadaveric study. Knee Surg Sports Traumatol Arthrosc 16:781–786

    Article  Google Scholar 

  20. Lee KT, Park YU, Kim JS, Kim JB, Kim KC, Kang SK (2011) Long-term results after modified Brostrom procedure without calcaneofibular ligament reconstruction. Foot Ankle Int 32:153–157

    Article  Google Scholar 

  21. Maffulli N, Del Buono A, Maffulli GD, Oliva F, Testa V, Capasso G, Denaro V (2013) Isolated anterior talofibular ligament Brostrom repair for chronic lateral ankle instability: 9-year follow-up. Am J Sports Med 41:858–864

    Article  Google Scholar 

  22. Michels F, Pereira H, Calder J, Matricali G, Glazebrook M, Guillo S, Karlsson J, Acevedo J, Batista J, Bauer T, Calder J, Carreira D, Choi W, Corte-Real N, Glazebrook M, Ghorbani A, Giza E, Guillo S, Hunt K, Karlsson J, Kong SW, Lee JW, Michels F, Molloy A, Mangone P, Matsui K, Nery C, Ozeki S, Pearce C, Pereira H, Perera A, Pijnenburg B, Raduan F, Stone J, Takao M, Tourne Y, Vega J (2018) Searching for consensus in the approach to patients with chronic lateral ankle instability: ask the expert. Knee Surg Sports Traumatol Arthrosc 26:2095–2102

    Article  Google Scholar 

  23. Nery C, Raduan F, Del Buono A, Asaumi ID, Cohen M, Maffulli N (2011) Arthroscopic-assisted Brostrom–Gould for chronic ankle instability: a long-term follow-up. Am J Sports Med 39:2381–2388

    Article  Google Scholar 

  24. Okuda R, Kinoshita M, Morikawa J, Jotoku T, Abe M (1999) Reconstruction for chronic lateral ankle instability using the palmaris longus tendon: is reconstruction of the calcaneofibular ligament necessary? Foot Ankle Int 20:714–720

    Article  CAS  Google Scholar 

  25. Park HJ, Cha SD, Kim SS, Rho MH, Kwag HJ, Park NH, Lee SY (2012) Accuracy of MRI findings in chronic lateral ankle ligament injury: comparison with surgical findings. Clin Radiol 67:313–318

    Article  Google Scholar 

  26. Park KH, Lee JW, Suh JW, Shin MH, Choi WJ (2016) Generalized ligamentous laxity is an independent predictor of poor outcomes after the modified brostrom procedure for chronic lateral ankle instability. Am J Sports Med 44:2975–2983

    Article  Google Scholar 

  27. Pellegrini MJ, Glisson RR, Wurm M, Ousema PH, Romash MM, Nunley JA 2nd, Easley ME (2016) Systematic quantification of stabilizing effects of subtalar joint soft-tissue constraints in a novel cadaveric model. J Bone Jt Surg Am 98:842–848

    Article  Google Scholar 

  28. Petersen W, Rembitzki IV, Koppenburg AG, Ellermann A, Liebau C, Bruggemann GP, Best R (2013) Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg 133:1129–1141

    Article  Google Scholar 

  29. Sarrafian SK (1993) Biomechanics of the subtalar joint complex. Clin Orthop Relat Res 290:17–26

    Google Scholar 

  30. Schneck CD, Mesgarzadeh M, Bonakdarpour A (1992) MR imaging of the most commonly injured ankle ligaments. Part II. Ligament injuries. Radiology 184:507–512

    Article  CAS  Google Scholar 

  31. Shon HC, Cho BK, Kim YM, Kim DS, Choi ES, Park KJ, Park JK (2011) A comparison between the modified Brostrom procedure using single and double suture anchor for chronic lateral ankle instability. J Korean Orthop Soc Sports Med 10:69–77

    Google Scholar 

  32. Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49

    Google Scholar 

  33. van Dijk CN, Tol JL, Verheyen CC (1997) A prospective study of prognostic factors concerning the outcome of arthroscopic surgery for anterior ankle impingement. Am J Sports Med 25:737–745

    Article  Google Scholar 

  34. Vuurberg G, Pereira H, Blankevoort L, van Dijk CN (2018) Anatomic stabilization techniques provide superior results in terms of functional outcome in patients suffering from chronic ankle instability compared to non-anatomic techniques. Knee Surg Sports Traumatol Arthrosc 26:2183–2195

    Article  CAS  Google Scholar 

  35. Weindel S, Schmidt R, Rammelt S, Claes L, v Campe A, Rein S (2010) Subtalar instability: a biomechanical cadaver study. Arch Orthop Trauma Surg 130:313–319

    Article  CAS  Google Scholar 

Download references


No external funding was used.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Ki-Sun Sung.

Ethics declarations

Conflict of interest

The authors have no conflict of interest.

Ethical approval

All procedures performed in this study involving human participants were in accordance with the ethical standards of our institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all participants.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 16 KB)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ko, K.R., Lee, WY., Lee, H. et al. Repair of only anterior talofibular ligament resulted in similar outcomes to those of repair of both anterior talofibular and calcaneofibular ligaments. Knee Surg Sports Traumatol Arthrosc 28, 155–162 (2020).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Chronic lateral ankle instability
  • Modified Broström procedure
  • Anterior talofibular ligament
  • Calcaneofibular ligament
  • Karlsson–Peterson score