J Korean Foot Ankle Soc.  2025 Mar;29(1):46-51. 10.14193/jkfas.2025.29.1.46.

Surgical Treatment for Simultaneous Medial and Lateral Ankle Instability in a Young Patient Engaged in High Physical Activities: A Case Report

• Choi JY
• Suh JS

• KMID: 2565872
• DOI: http://doi.org/10.14193/jkfas.2025.29.1.46

Abstract

Multidirectional joint instability is a condition where laxity occurs in two or more directions. This condition typically arises congenitally or because of hypermobility or repetitive, excessive physical activity. It can also occur from chronic damage to the joint capsule and multiple ligaments, causing a breakdown in stability. Despite the numerous studies conducted on multidirectional instability of the shoulder, there is a lack of published research on multidirectional instability of the ankle. This paper reports the case of a male patient in his early 30s, engaged in high-demand physical activity, who presented with simultaneous medial and lateral ankle instability. The patient underwent a combination of procedures, including an anterior talofibular ligament reconstruction with suture tape, deltoid ligament reattachment with suture anchors, anteroinferior tibiofibular ligament reconstruction with suture tape, and syndesmotic screw fixation with Tightrope insertion. The patient was followed up for one year postoperatively. This paper reports the clinical outcomes with a review of the relevant literature.

Keyword

Ankle; Ankle instability; Multidirectional instability; Syndesmosis; Ligament reconstruction

Figure

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  Figure 1 Radiographic findings of the ankle and hindfoot alignment. On weight-bearing anteroposterior radiograph of the ankle (A), a valgus tilt of the talus at 3.9° was shown and the mortise view (B) suggested the existence of os subfibulare and widening of the syndesmosis. Hindfoot alignment view (C) present a valgus deviation of the hindfoot with more pronounced valgus tilt of the talus compared to the anteroposterior radiograph. Likewise, hip-to-calcaneus radiograph (D) also demonstrated a slight valgus deviation of the hindfoot relative to the overall axis of the lower limb.

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  Figure 2 Stress radiographs using the Telos device (METAX). Anterior drawer radiograph (A) revealed 10 mm of anterior talar translation, which was 3 mm greater than the contralateral side and varus stress radiograph (B) showed a 1.9º varus tilt of the talus. Valgus stress radiograph (C) demonstrated a 10.4º valgus tilt of the talus, which showed an increase of approximately 7º compared to the weight-bearing anteroposterior radiograph.

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  Figure 3 Additional preoperative imaging findings. Magnetic resonance imaging of the ankle showed attenuation and loss of continuity in the deltoid ligament at its medial malleolar attachment, suggesting a possible tear (A) and the anterior talofibular ligament was ruptured at its fibular attachment, resulting in loss of continuity (B). Preoperative computed tomographic scan (C) demonstrated anterior displacement of the fibula within the incisura fibularis at the level of the syndesmosis.

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  Figure 4 Operative procedure applied in this study. First, a hole was drilled into the Chaput tubercle of the tibia, and a suture tape (Internal brace, Arthrex Inc.) along with an interference screw was inserted (A). With the ankle positioned in neutral, the tape was passed 45º inferolaterally and fixed with an interference screw at the anterior aspect of the fibula (B). A 4-cm longitudinal incision was then made at the tip of the medial malleolus, and after soft tissue dissection, an avulsion injury of the deltoid ligament was confirmed (C). One suture anchor (Trushot, CONMED Inc.) was inserted at anterior and posterior aspect of the medial malleolus each, and the deltoid ligament was reattached using these anchors (D). The ankle was then maintained in neutral position, and a Tightrope (Arthrex Inc.) was inserted from the posterolateral fibula, 2 cm proximal to the joint, toward the anteromedial aspect. However, due to insufficient tension and persistent widening of the syndesmosis, an additional 3.5 mm cancellous screw was inserted just below this area in the same direction to reinforce the fixation (E). Finally, the anterior talofibular ligament (ATFL) tear was confirmed at the anterior aspect of the lateral malleolus, and another suture tape was fixed using interference screws in both the fibula and talus, following the path of the ATFL (F).

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  Figure 5 Radiographic findings at the final follow-up. At the final follow-up, weight-bearing anteroposterior radiograph of the ankle showed a persistent valgus tilt of the talus at 3º, similar to the preoperative measurement (A). However, hindfoot alignment had improved, with less hindfoot valgus deviation compared to preoperative one (B). The anterior drawer radiograph demonstrated a 2 mm improvement in anterior talar translation compared to preoperatively (C), and valgus stress radiograph showed that valgus instability had significantly improved, with minimal talar tilt remaining (D).

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