J Korean Foot Ankle Soc.  2018 Sep;22(3):91-94. 10.14193/jkfas.2018.22.3.91.

Indications of Lateral Ankle Ligament Reconstruction with a Free Tendon and Associated Evidence

  • 1Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea.
  • 2Department of Orthopedic Surgery, Konkuk University School of Medicine, Seoul, Korea. jungfoot@hanmail.net


Ankle sprain is one of the most common musculoskeletal injuries. Although most ankle sprains respond well to conservative measures, chronic instability following an acute sprain has been reported to occur in 20% to 40% of patients. Some individuals are eventually indicated for a lateral ankle ligament reconstruction due to persistent ankle instability. More than 80 surgical procedures have been described to address lateral ankle stability. These range from direct repair of the anterior talofibular ligament (ATFL) and of the calcaneofibular ligament (CFL) to reconstructions based on the use of autograft or allograft tissues. However, the best surgical option remains debatable. The modified Broström procedure is most widely used for direct ligament repair, but not always possible because of the poor ATFL or CFL quality or deficiency of these ligaments, which prevents effective shortening imbrication. Furthermore, the importance of a CFL reconstruction has been emphasized recently. On the other hand, it is difficult to achieve an efficient CFL reconstruction during the Broström procedure. Others have reported that an anatomic reconstruction of injured ligaments restores the normal resistance to anterior translation and inversion without restricting subtalar or ankle motion, and as a result, anatomic reconstructions for lateral ankle instability utilizing an autograft or allograft tendon have gained popularity.


Ligament reconstruction; Sprain; Instability; Free tendon

MeSH Terms

Ankle Injuries
Lateral Ligament, Ankle
Sprains and Strains


  • Figure 1. Schematic diagram of the anatomical reconstruction of the anterior talofibular ligament and calcaneofibular ligament using free tendon and biotenodesis screws.

Cited by  2 articles

Surgical Treatment of Chronic Lateral Ankle Instability: Repair versus Reconstruction
Keun Soo Kim, Young Uk Park
J Korean Foot Ankle Soc. 2019;23(1):1-5.    doi: 10.14193/jkfas.2019.23.1.1.

Current Trends in the Treatment of Ankle Ligament Injuries: Analysis of the Korean Foot and Ankle Society (KFAS) Member Survey
Byung-Ki Cho, Jaeho Cho, Myoungjin Lee, Jun Young Lee, Su-Young Bae
J Korean Foot Ankle Soc. 2022;26(1):22-29.    doi: 10.14193/jkfas.2022.26.1.22.



1. Ferran NA, Maffulli N. Epidemiology of sprains of the lateral ankle ligament complex. Foot Ankle Clin. 2006; 11:659–62.
2. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007; 42:311–9.
3. Colville MR, Marder RA, Boyle JJ, Zarins B. Strain measurement in lateral ankle ligaments. Am J Sports Med. 1990; 18:196–200.
4. Burks RT, Morgan J. Anatomy of the lateral ankle ligaments. Am J Sports Med. 1994; 22:72–7.
5. Meyer JM, Garcia J, Hoffmeyer P, Fritschy D. The subtalar sprain. A roentgenographic study. Clin Orthop Relat Res. 1988; 226:169–73.
6. Sammarco VJ. Complications of lateral ankle ligament reconstruction. Clin Orthop Relat Res. 2001; 391:123–32.
7. Caprio A, Oliva F, Treia F, Maffulli N. Reconstruction of the lateral ankle ligaments with allograft in patients with chronic ankle instability. Foot Ankle Clin. 2006; 11:597–605.
8. Tourné Y, Mabit C. Lateral ligament reconstruction procedures for the ankle. Orthop Traumatol Surg Res. 2017; 103:S171–81.
9. de Vries JS, Krips R, Sierevelt IN, Blankevoort L, van Dijk CN. Interventions for treating chronic ankle instability. Cochrane Database Syst Rev. 2011; 8:CD004124.
10. Krips R, Brandsson S, Swensson C, van Dijk CN, Karlsson J. Anatomical reconstruction and Evans tenodesis of the lateral ligaments of the ankle. Clinical and radiological findings after follow-up for 15 to 30 years. J Bone Joint Surg Br. 2002; 84:232–6.
11. Chrisman OD, Snook GA. Reconstruction of lateral ligament tears of the ankle. An experimental study and clinical evaluation of seven patients treated by a new modification of the Elmslie procedure. J Bone Joint Surg Am. 1969; 51:904–12.
12. Evans DL. Recurrent instability of the ankle; a method of surgical treatment. Proc R Soc Med. 1953; 46:343–4.
13. Watson-Jones R. Fractures and joint injuries. Vol II. 4th ed.Edinburgh: E&S Livingstone;1955.
14. Kjaersgaard-Andersen P, Madsen F, Frich LH, Wethelund JO, Sojbjerg JO. Lateral hindfoot instability treated with the Evans tenodesis: a biomechanical analysis. J Foot Surg. 1990; 29:25–32.
15. Kjaersgaard-Andersen P, Sojbjerg JO, Wethelund JO, Helmig P, Madsen F. Watson-Jones tenodesis for ankle instability. A mechanical analysis in amputation specimens. Acta Orthop Scand. 1989; 60:477–80.
16. Rosenbaum D, Bertsch C, Claes LE. NOVEL Award 1996: 2nd prize tenodeses do not fully restore ankle joint loading characteristics: a biomechanical in vitro investigation in the hind foot. Clin Biomech (Bristol, Avon). 1997; 12:202–9.
17. Krips R, van Dijk CN, Halasi PT, Lehtonen H, Corradini C, Moyen B, et al. Long-term outcome of anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a multicenter study. Foot Ankle Int. 2001; 22:415–21.
18. Ahlgren O, Larsson S. Reconstruction for lateral ligament injuries of the ankle. J Bone Joint Surg Br. 1989; 71:300–3.
19. Broström L. Sprained ankles. VI. Surgical treatment of ‘‘chronic''ligament ruptures. Acta Chir Scand. 1966; 132:551–65.
20. Gould N, Seligson D, Gassman J. Early and late repair of lateral ligament of the ankle. Foot Ankle. 1980; 1:84–9.
21. Karlsson J, Bergsten T, Lansinger O, Peterson L. Surgical treatment of chronic lateral instability of the ankle joint. A new procedure. Am J Sports Med. 1989; 17:268–73.
22. Bell SJ, Mologne TS, Sitler DF, Cox JS. Twenty-six-year results after Broström procedure for chronic lateral ankle instability. Am J Sports Med. 2006; 34:975–8.
23. Karlsson J, Eriksson BI, Bergsten T, Rudholm O, Swärd L. Comparison of two anatomic reconstructions for chronic lateral instability of the ankle joint. Am J Sports Med. 1997; 25:48–53.
24. Coughlin MJ, Schenck RC, Grebing BR, Treme G. Comprehensive reconstruction of the lateral ankle for chronic instability using a free gracilis graft. Foot Ankle Int. 2004; 25:231–41.
25. Girard P, Anderson RB, Davis WH, Isear JA, Kiebzak GM. Clinical evaluation of the modified Brostrom-Evans procedure to restore ankle stability. Foot Ankle Int. 1999; 20:246–52.
26. Paterson R, Cohen B, Taylor D, Bourne A, Black J. Reconstruction of the lateral ligaments of the ankle using semi-tendinosis graft. Foot Ankle Int. 2000; 21:413–9.
27. Sugimoto K, Takakura Y, Kumai T, Iwai M, Tanaka Y. Reconstruction of the lateral ankle ligaments with bone-patellar tendon graft in patients with chronic ankle instability: a preliminary report. Am J Sports Med. 2002; 30:340–6.
28. Becker HP, Rosenbaum D, Zeithammel G, Gnann R, Bauer G, Gerngross H, et al. Tenodesis versus carbon fiber repair of ankle ligaments: a clinical comparison. Clin Orthop Relat Res. 1996; 325:194–202.
29. Marrale J, Morrissey MC, Haddad FS. A literature review of autograft and allograft anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2007; 15:690–704.
30. Jeys L, Korrosis S, Stewart T, Harris NJ. Bone anchors or interference screws? A biomechanical evaluation for autograft ankle stabilization. Am J Sports Med. 2004; 32:1651–9.
31. Jung HG, Shin MH, Park JT, Eom JS, Lee DO, Lee SH. Anatomical reconstruction of lateral ankle ligaments using free tendon allografts and biotenodesis screws. Foot Ankle Int. 2015; 36:1064–71.
32. Jung HG, Kim NR, Kim TH, Eom JS, Lee DO. Magnetic resonance imaging and stress radiography in chronic lateral ankle instability. 2017; 38:621–6.
33. Jung HG, Kim TH, Park JY, Bae EJ. Anatomic reconstruction of the anterior talofibular and calcaneofibular ligaments using a semitendinosus tendon allograft and interference screws. Knee Surg Sports Traumatol Arthrosc. 2012; 20:1432–7.
34. Kim HN, Jeon JY, Dong Q, Noh KC, Chung KJ, Kim HK, et al. Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon. Knee Surg Sports Traumatol Arthrosc. 2015; 23:1877–85.
35. Dierckman BD, Ferkel RD. Anatomic reconstruction with a semitendinosus allograft for chronic lateral ankle instability. AM J Sports Med. 2015; 43:1941–50.
36. Miller AG, Raikin SM, Ahmad J. Near-anatomic allograft tenodesis of chronic lateral ankle instability. Foot Ankle Int. 2013; 34:1501–7.
37. Wang B, Xu XY. Minimally invasive reconstruction of lateral ligaments of the ankle using semitendinosus autograft. Foot Ankle Int. 2013; 34:711–5.
38. Xu X, Hu M, Liu J, Zhu Y, Wang B. Minimally invasive reconstruction of the lateral ankle ligaments using semitendinosus autograft or tendon allograft. Foot Ankle Int. 2014; 35:1015–21.
39. Youn H, Kim YS, Lee J, Choi WJ, Lee JW. Percutaneous lateral ligament reconstruction with allograft for chronic lateral ankle instability. Foot Ankle Int. 2012; 33:99–104.
40. Kennedy JG, Smyth NA, Fansa AM, Murawski CD. Anatomic lateral ligament reconstruction in the ankle: a hybrid technique in the athletic population. Am J Sports Med. 2012; 40:2309–17.
41. Michels F, Cordier G, Guillo S, Stockmans F. ESKKA-AFAS Ankle Instability Group. Endoscopic ankle lateral ligament graft anatomic reconstruction. Foot Ankle Clin. 2016; 21:665–80.
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