When Is Ankle Arthroscopy Indicated in Ankle Instability?

Annunziato Amendola, MD and Davide E. Bonasia, MD

Ankle sprains are among the most common injuries encountered in work and sport, with well over 2 million individuals experiencing ankle ligament trauma each year in the United States. Although most of these respond well to conservative management, acute ankle sprains are frequently associated with pathology resulting in chronic symptoms, including pain and instability, which persist beyond the expected recovery period. Although it is generally accepted that arthroscopy can be very helpful in the diagnosis and treatment of many ankle injuries and joint disorders, there is still some controversy regarding specic indications and effectiveness for its use. Given that these therapeutic and diagnostic indications are still being dened, the purpose of this article was to review the use and indications of arthroscopy or periarticular endoscopy as an adjunct to treating ankle instability at the time of open ligamentous stabilization. Ankle arthroscopy before lateral ligaments reconstruction will aid the surgeon in assessing for additional damage while conferring minimal additional time or morbidity. Surgically amenable lesions (ie, chondral lesions, loose bodies, associated instabilities, synovitis, impingements, ossicles, and peroneal tendon pathologies) can then be addressed, and the patient can be more accurately counseled regarding the condition of his ankle. Although it is likely that preoperative arthroscopy will improve outcomes in surgically stabilized ankles, there is a lack of controlled prospective studies that can truly assess its efcacy. Oper Tech Sports Med 18:2-10 2010 Elsevier Inc. All rights reserved. KEYWORDS ankle instability, arthroscopy, ankle sprains, pain and instability

nkle sprains are among the most common injuries encountered in work and sport, with more than 2 million individuals experiencing ankle ligament trauma each year in the United States.1 Although most of these respond well to conservative management,2 acute ankle sprains are frequently associated with pathology resulting in chronic symptoms, including pain and instability, which persist beyond the expected recovery period. In a survey of 84 high school varsity basketball players, Smith et al3 reported that 70% had experienced an ankle sprain in their athletic lifetime. Fifty percent of these reported chronic symptoms after an acute sprain, with 15% noting a performance decit because of the dysfunction. Similarly, Staples4 found 41% of patients with lateral ankle sprains continued to experience symptoms ranging from mild soreness to severe disability at long-term follow-up. The most common causes of disability after

University of Iowa Sports Medicine, Iowa City, IA. Address reprint requests to Annunziato Amendola, MD, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA 52242. E-mail: ned-amendola@uiowa.edu

chronic ankle sprains in addition to the excessive laxity are the associated pathologies that develop with the recurrent episodes of giving way or inversion sprains. These may include intra-articular pathology (chondral lesions, loose bodies, ossicles, synovitis, and arthrosis), impingement lesions (anterior and anterolateral), and other instabilities other than lateral (subtalar, syndesmotic, and medial). These conditions are often associated with chronic ankle pain in addition to the ankle laxity. Therefore, when dealing with athletes with chronic ankle instability, it is important to conduct a thorough evaluation and assess all the causes of pain and instability before embarking on a treatment plan. Although it is generally accepted that arthroscopy can be very helpful in the diagnosis and treatment of many ankle injuries and joint disorders, there is still some controversy regarding specic indications and effectiveness for its use. Given that these therapeutic and diagnostic indications are still being dened, the purpose of this article was to review the use and indications of arthroscopy or periarticular endoscopy as an adjunct to treating ankle instability at the time of open ligamentous stabilization.

1060-1872/10/$-see front matter 2010 Elsevier Inc. All rights reserved. doi:10.1053/j.otsm.2009.11.004

Ankle arthroscopy

3 jumping has also been proposed. Controversy continues to surround the diagnosis as positive stress radiographs do not correlate with symptoms. Magnetic resonance imaging (MRI) has recently been shown to be accurate in displaying ligamentous injury of the subtalar joint. Initial treatment is the same rehabilitation protocol as for lateral instability. Operative treatment involves reconstructing the relevant anatomy or performing the extensor retinacular advancement (Gould modication) at the time of lateral ankle ligament stabilization.

Lateral Ankle Instability and Associated Instabilities: Indications for Stabilization

Chronic Lateral Ankle Instability
Chronic lateral ankle instability must be thoroughly evaluated to determine whether true mechanical instability due to ligamentous laxity exists. This is differentiated from functional instability related to muscular weakness or pain inhibition reexes from associated injury. If pain is is not present between sprains, true mechanical instability may be the primary problem. Stress radiographs are controversial because of the large variability in physiological values and the lack of correlation with clinical symptoms. Initial treatment for all patients, regardless of the duration of the instability, involves a therapy program of peroneal muscle strengthening and proprioceptive training, combined with the use of a lace-up brace for high-risk activities. This regimen is effective in 90% of patients. The remaining patients are candidates for operative stabilization. If pain is present between instability episodes and an associated lesion has been identied, it may be an option to treat this cause before considering surgical stabilization of the ankle or to treat it concurrently. If no clear associated lesion is identied, arthroscopy is carried out immediately preceding the lateral repair. The preferred technique is the Gould modication of the Brostrm procedure, an anatomical shortening and reinsertion of the anterior talobular ligament (ATFL) and calcaneo-bular ligament (CFL), reinforced with the inferior extensor retinaculum and distal bular periosteum. Ninety percent good or excellent results have been reported with this procedure. Non-anatomical reconstructions that sacrice all or part of the peroneus brevis tendon to provide a tenodesis effect across the ankle and subtalar joints have been popular in the past. Concerns regarding the loss of the dynamic stabilizing effect of the peroneus brevis and overtightening of the subtalar joint have contributed to their decrease in popularity. Tenodesis procedures that attempt to anatomically replace the ATFL and CFL5 appear to have better functional and radiologic success compared with those that do not replicate the course of the native ligaments. Recalcitrant inversion injury in the presence of a varus hind foot may warrant consideration of supramalleolar or calcaneal osteotomy. More recently, anatomical reconstruction using autogenous or allogenic tissue has received some attention,6,7 but no controlled trials have been published.

Medial (Deltoid) Instability

Medial (deltoid) instability has also received signicant attention in the recent past. This can occur alone or in conjunction with lateral instability to cause excessive rotatory instability of the talus within the mortise. This may be associated with a history of trauma, valgus hind foot, or posterior tibialis tendon dysfunction. Although limited data are available in the published data regarding medial ankle instability in patients with lateral ankle instability, it is common to observe an associated lesion of the deltoid ligament (6%-40%). Similarly, a high incidence of lateral ligaments lesions (77%)8 is detectable in chronic medial instability. Hintermann et al8 stated that this phenomenon is probably due to repetitive rotatory shift of the talus within the medial ankle mortise, provoking overuse and attenuation of the lateral ankle ligaments. Nevertheless, the authors raised the doubt that the primum movens of combined medial and lateral instability can be the lateral insufciency. Another interesting datum regarding medial ankle instability is the high association with chondral lesions (100%).9 The diagnosis is often underestimated,9 and arthroscopy has an important role in conrming the diagnosis. The clinical relevance of medial ligament insufciency is not exactly known and the wide tendency is to not treat it surgically, as in deltoid disruptions associated with ankle fractures.10,11 The only study reporting results on medial ankle stabilization is the one by Hintermann et al.8 The authors treated 52 consecutive ankles with medial ankle instability. The surgical technique involved an arthroscopic diagnostic procedure before an open medial repair with anchors and with augmentation (plantaris tendon graft), if the tissue quality was poor. Additional lateral ligaments shortening and reinsertion were performed if an associated lateral instability was detected. At an average of 4.43 years after surgery, the clinical result was considered good or excellent in 46 cases (90%), fair in 4 cases (8%), and poor in 1 case (2%).

Chronic Subtalar Instability

Chronic subtalar instability is believed to be associated with lateral mechanical instability in 10%-25% of patients. The structures considered most important in stabilizing the subtalar joint are the extensor retinaculum, CFL, the lateral talocalcaneal ligament, the interosseous talocalcaneal ligament, and the cervical ligament. The mechanism of injury involves supination with the ankle in dorsiexion or simply the continuation of the arc of injury in a standard inversion ankle sprain. Chronic repetitive stress on the ligaments due to

Syndesmotic Instability
Syndesmotic instability usually occurs with a disruption of the distal tibiobular syndesmosis and is a common nding in chronic lateral instabilities, with an incidence ranging from 7% to 29%. The treatment of syndesmotic instability regardless of the involvement of lateral ligaments is still controversial.12 Current indications for surgical treatment of acute syndesmosis injuries include frank diastasis of the syndesmosis or diastasis on stress radiographs.13 In these cases, surgical treatment should include reduction and trans-syndesmotic

A. Amendola and D.E. Bonasia

Figure 1 Syndesmotic instability. (A) Normal preoperative radiograph. (B,C) Disruption of the anterior tibiobular ligament. (D) Anterior tibiobular ligament remnant after arthroscopic debridement.

xation with 1 or 2 metallic screws.13 Arthroscopic evidence of syndesmotic instability is another indication for operative treatment. Nevertheless, when there are no radiographic signs of syndesmotic diastasis, the treatment of choice is controversial. Ogilvie-Harris et al14 treated 9 patients with syndesmotic instability and normal radiographs. The diagnosis was made clinically and conrmed arthroscopically. The treatment involved an arthroscopic removal of the torn portions of the interosseous ligament and posterior-inferior tibiobular ligament along with a debridement of the chondral damage if present. No screw xation was performed. Seven patients were completely satised with the result and only 2 were partially satised. The authors concluded that the pain was caused by the intra-articular disruption, not by biomechanical laxity, and that arthroscopic debridement was sufcient in these patients. Similar results and conclusions were reported by Han et al15 in their 20-patient series with arthroscopic diagnosis and treatment of chronic syndesmosis injuries. By contrast, Wolf and Amendola16 advocate the use of percutaneous xation. A total of 14 athletically active patients underwent arthroscopic debridement at the level of the anterior-inferior tibiobular ligament (to allow adequate visualization of the syndesmosis) and percutaneous transsyndesmotic xation with arthroscopic demonstration of syndesmotic instability. Three patients required additional lateral ligament reconstruction (Brostrm). Two of 14 patients (14%) had an excellent result, 10 of 14 (71%) had a good result, and 2 of 14 (14%) had a fair result (according to

Edwards and DeLee scale17). Schuberth et al18 at 24-month minimum follow-up reported excellent results in 6 patients with latent syndesmotic instability, treated with arthroscopic debridement and percutaneous xation (Figs. 1 and 2).

Associated Pathology at Time of Ankle Stabilization: Need for Arthroscopy

Intra-articular Pathology
Intra-articular pathology is a common nding in chronic ankle instability. The accuracy of arthroscopy in diagnosing ankle pathologies associated with lateral instability has been reported by many authors. A recent investigation by Hinterman et al19 demonstrated the sensitivity of arthroscopy in diagnosing abnormalities in the chronically unstable ankle. In their study, 148 patients with chronic ankle instability (greater than 6 months) underwent arthroscopic evaluation. All structural changes were noted and compared with the original diagnosis as assessed by standardized physical examination and imaging. Arthroscopy demonstrated that more than 50% of the cases had cartilage lesions of the talus, whereas the preoperative diagnosis was made in only 4% of the patients. Arthroscopic examination also revealed cartilage lesions of the tibial pilon (8%), medial malleolus (11%), and lateral malleolus (2.5%) that were not identied preoperatively. Furthermore, arthroscopic examination provided a more

Ankle arthroscopy

Figure 2 Post-operative radiographs of the case described in Figure 1, after syndesmotic xation with Arthrex TightRope (Arthrex, Naples, FL).

sensitive means to diagnose medial and rotational instability as well as visualize synovitis. Similar ndings were seen in Kiblers20 study of 44 patients (46 ankles) who underwent a modied Brostrm procedure to repair the ATFL and the CFL in chronically symptomatic ankles. Arthroscopy identied intraarticular pathology in 38 (83%) of the 46 ankles. Preoperative diagnosis of intra-articular pathologies based on physical examination was made in only 28 (60%) cases. Takao et al21 reported the results of 14 patients with apparent functional ankle instability. All subjects had no clinically demonstrable lateral instability and underwent standard stress radiography, MRI, ankle arthroscopy, and anatomical reconstruction of ATFL. Arthroscopic assessment revealed 3 cases with scar tissue and no ligamentous structure, 9 cases with partial ligament tears and scar tissue on the disrupted ATFL ber, and 2 cases of abnormal course of the ligament at the bular or talar attachment. MRI revealed the following: 5 cases of discontinuity of the ATFL, 2 cases of narrowing of the ATFL, 4 cases of high-intensity lesion in the ATFL, and 3 normal cases. The authors concluded that both MRI and arthroscopy are excellent tools in the diagnosis of ankle disorders, with arthroscopy being more accurate in detecting small lesions. Taga et al22 performed an arthroscopic investigation of ankles before lateral ligament reconstruction to look for associated cartilage lesions. Of the 22 patients with chronic ankle instability, chondral lesions were detected in 21 (95%). The articular surface of the medial tibial plafond was noted to be the most frequently and severely involved site with 7 (33%) of the ankles exhibiting grade 3 or 4 lesions at this location. This was similar to previous reports of medial degeneration after chronic lateral instability.23 Furthermore, given that the higher grade injuries were not noted radiographically, only arthroscopic evaluation could accurately diagnose the presence of associated chondral lesions. They

suggested that arthroscopic evaluation should be performed to evaluate ankles with lateral ligament damage to aid patient counseling and direct further intervention. Choi et al24 described 63 (96.9%) intra-articular lesions out of 65 cases of lateral ankle instability, of which 53 (81.5%) showed soft-tissue impingement as the most common associated lesion. Other associated intra-articular lesions included ossicles at the lateral malleolus (38.5%), syndesmosis widening (29.2%), and osteochondral lesion of the talus (23.1%). Komenda and Ferkel25 in their series of 55 patients with lateral instability demonstrated intra-articular abnormalities in 93% of ankles before lateral ankle stabilization. However, the incidence of chondral injuries in this study was only 25% compared with 95% reported by Taga et al.22 Additional abnormalities, including loose bodies (22%), synovitis (69%), adhesions (15%), and osteophytes (11%) were discovered. Ankle arthroscopy seems to be essential even when an open surgery is planned, for example, in lateral stabilization. Ferkel and Chams26 in their series of 21 patients with lateral ankle instability reported that arthroscopy showed 95% of intra-articular lesions, and only 20% of them could be noted during the following open procedure. In contrast, OgilvieHarris et al14 stated that in the ankles treated with lateral ligament reconstruction, the chondral lesions detected arthroscopically (23 out of 27 patients) could all have been treated during open surgery. Nevertheless, the authors concluded that arthroscopy was useful to conrm the abnormal talar tilt when the diagnosis of lateral instability was not certain. In review of the published data, high rate of associated intra-articular lesions is evident along with the essential role that arthroscopy has in detecting them. Nevertheless, the types of lesions differ somewhat across studies, which may reect the variety of anatomical lesions likely to produce chronic symptoms. Furthermore, there are still some debated

A. Amendola and D.E. Bonasia

Figure 3 Magnetic resonance imaging showing a chondral lesion of the postero-medial aspect of the talar dome in a patient with associated lateral ankle instability.

issues about chondral defects (Fig. 3). Although other intraarticular disorders reported good results with arthroscopic treatment and seem to not affect the outcome of lateral reconstruction,14,24,25 it is still controversial whether chondral lesions correlate with poor results. Komenda and Ferkel25 in the previously cited study reported good or excellent results in 96% of cases, further suggesting a benet for the use of arthroscopy in diagnosing and treating all intra-articular lesions at the time of ligament repair. Okuda et al27 reported a 63% rate of focal chondral lesion diagnosed arthroscopically in a 30-patient series. The lesions were located on the medial side of the tibial plafond in 13 ankles (43%), on the lateral side in 2 ankles (7%), on the lateral side of the talar dome in 3 ankles (10%), and on the medial side in 9 ankles (30%). The authors noticed no signicant differences in the clinical and radiologic results between patients with and without chondral damages. Hence, they concluded that lateral stabilization can be successful regardless of the presence of focal chondral lesions in patients with chronic lateral ankle instability when preoperative weight-bearing radiographs of the ankle do not show any joint space narrowing. Nevertheless, long-term results of patients with chondral lesion are not yet known. In contrast, Takao et al28 described the results of 16 lateral ankle instabilities with moderate arthrosis (7 cases with stage 2 and 9 cases with stage 3 degeneration, according to Takakura classication). All patients underwent lateral stabilization and arthroscopic drilling of the cartilage lesions. The authors recommended the combined procedures only for stage 2 arthrosis. Similar results were reported by Taga et al22 in the previously described article, which stated that all the patients included in the study had sustained functional stability and improved mobility at 1 year follow-up. However, 4 of the patients with grade 3 or 4 lesions continued to experience medial ankle pain with activity. Physical examination

of these patients revealed point tenderness at the anteromedial joint line corresponding to the location of the chondral lesions. The authors concluded that these symptomatic lesions may affect the nal outcome of ankle stabilization procedures. Choi et al24 in a 65-case series evaluated the effect of associated lesions on the outcome of lateral ankle stabilization and concluded that arthroscopic diagnosis and treatment of intra-articular lesions is a safe and effective method. Nevertheless, the presence of any combination of associated intra-articular lesions resulted in a poor outcome. The strongest risk indicators for patients dissatisfaction were syndesmosis widening, osteochondral lesions of the talus, and ossicles. Another controversy in the published data is whether chondral lesions are correlated to the degree and the duration of ankle instability (Fig. 4). In the study by Taga et al,22 the severity and extent of cartilage lesions increased with the duration of symptoms but did not correlate with the number of ligaments involved. The authors concluded that even single ligament lesions should be treated to prevent further cartilage damage. In contrast, Hintermann et al19 showed no correlation between the severity and extent of cartilage lesions and the duration of ankle instability, but found an increased incidence of cartilage lesions in the presence of deltoid ligament rupture. Similar results were reported by Schfer et al.9 Furthermore, Lfvenberg et al29 evaluated 37 patients with chronic ankle instability 20 years after the diagnosis and only 6 (16%) of them developed chondral degenerative changes.

Bony or Soft-Tissue Impingement

Bony or soft-tissue impingement is associated with lateral ankle instabilities in 28%-81% of the cases. Of bony impingements, anterior impingement is more common (Fig. 5). Al-

Ankle arthroscopy

Figure 4 Chondral lesion of the talar dome. (A) Chondral ap. (B) Debridement and curetting of the lesion, after aps removal. (C) The lesion after the debridement.

though anterior impingement (spurs on the anterior tibia and anterior neck of the talus) indicates a long-standing disorder of the ankle, sprains usually exacerbate the symptoms that may require surgery in previously asymptomatic patients.14 Ogilvie-Harris et al14 treated 11 patients with anterior impingement, which became symptomatic after multiple sprains. The patients complained of pain, stiffness, limp, and limitation of activities and not of substantial instability. The spurs were arthroscopically removed without any other combined procedure. The range of motion in dorsiexion was signicantly improved from an average of 0 dorsiexion preoperatively to 10 postoperatively. Nine of the patients were completely satised, whereas 2 were only partially satised. Similar conclusions are reported by van Dijk,30 but only when anterior impingement is associated to initial chondral degeneration. Another condition associated with ankle sprains and instability is the anterolateral impingement syndrome, which is a synovial thickening consistent with impingement in the anterolateral ankle gutter.14,31 In these patients the pain is characteristically increased by plantar exion of the ankle and a talar dome chondral lesion is often associated. Arthroscopy yields good results in treating this condition. Ferkel et al31 evaluated 31 patients with anterolateral impingements. Ar-

throscopic synovectomy and debridement of scar tissue from the lateral gutter was performed in all patients. The outcomes of more than a 2 year follow-up were excellent in 15 cases, good in 11, fair in 4, and poor in 1. Ogilvie-Harris et al14 treated arthroscopically 17 cases with anterolateral impingement. Thirteen patients were completely satised, 3 partially satised, and only 1 was dissatised with the results.

Loose Bodies and Avulsion Fractures

Loose Bodies and avulsion fractures can commonly occur with recurrent sprains. Often avulsion injuries occur around the ankle (medial malleollus, bular malleollus, medial and lateral wall of the talus, and postero medial talus). At the time of ankle stabilization, removing these loose bodies and unstable avulsions may be of benet to prevent any discomfort when returning to play after stabilization (Fig. 6).

Peroneal Tendon Pathology

Another condition that may be associated with chronic ankle instability is peroneal tendons pathology, even though the real incidence of this association is unknown. As the peroneal muscles act as lateral ankle stabilizers, more strain is placed

Figure 5 (A) Anterior bony impingement. (B) Result after arthroscopic osteoplasty.

A. Amendola and D.E. Bonasia

These conditions, along with adhesions, tendon ruptures, and exostosis, can be easily treated with tendoscopy (Fig. 7), when a proper conservative treatment fails. Endoscopic release in combination with synovectomy has several advantages: out-patient procedure, diminished pain, quick work and sports resumption and no need for a plaster cast.32 In patients with recurrent dislocation of the peroneal tendons, the patient complains of lateral instability, giving way, lateral pain, and, occasionally, a snapping sensation.32 The dislocation can be reproduced by active eversion of the slightly dorsiexed foot against resistance. When the location cannot be reproduced, the cause of the snap often remains unclear.32 Grade 1 and 2 injuries of the superior peroneal retinaculum accounts for more than 80% of peroneal instabilities.33 In these cases, the anatomical reattachment of the retinaculum is indicated.33 Lui33 described the endoscopic technique for superior retinaculum repair, using 3 suture anchors inserted in the bula. This procedure seems to have the advantages of minimal invasive surgery, better cosmesis results, and less subjective tightness of peroneal tendons.33 An endoscopic approach can allow better assessment of retinaculum integrity, grading of the injury, detection of other pathology (eg, exostosis of the retro malleolar sulcus),33 and can also be easily converted to an open procedure.

Figure 6 Lateral malleolus bony avulsion in a young basketball player with chronic lateral ankle instability.

on these tendons in chronic lateral instability resulting in hypertrophic tendinopathy, tenosynovitis, and, ultimately, in (partial) tendon tears.32 On physical examination, there is tenderness on palpation, edema, and increase of symptoms on active eversion against resistance.32

Figure 7 (A) Portals positioning for tendoscopy and modied lateral approach for Brostrm procedure, including the portals. (B,C) Endoscopic images of the peroneal tendons.

Ankle arthroscopy

Figure 8 Ankle arthroscopy associated with Brostrm procedure (A) Positioning of the anteromedial and anterolateral (AL) portals and approach to the lateral compartment, including the AL portal. (B) AL approach for Brostrm procedure.

In the patients with peroneal snap without a clinically evident dislocation over the lateral malleolus, the peroneal tendons are likely to snap over each other at the level of the tip of the lateral malleolus. The treatment of this condition is still debated. Resection of the peroneal brevis vincula and tenodesis has been proposed, but the results are still controversial.32

Conclusions and Senior Authors Approach

Chronic dysfunction after an ankle sprain or recurrent sprains is a common occurrence. Despite surgical restoration of objective stability, many of these ankles are likely to continue to be problematic. In addition, traditional approaches to repair damaged ligaments offer limited exposure to intraarticular structures. As the use of arthroscopy expands, previously undiagnosed articular lesions suggest etiologies for unsatisfactory outcomes. Ankle arthroscopy has progressed immensely over the past several decades as previous limitations give way to improved technology, experiences, and techniques. Its use before ankle ligament reconstruction will aid the surgeon in assessing for additional damage while conferring minimal additional time or morbidity. Surgically amenable lesions can then be addressed and the patients can be more accurately counseled regarding the condition of their ankle. Although it is likely that preoperative arthroscopy will improve outcomes in surgically stabilized ankles, controlled prospective studies are lacking to truly assess its efcacy.

Authors Current Approach to Lateral Ankle Instability and the Use of Arthroscopy
Presently, once the decision to stabilize an ankle has been made, my preferred method is a modied Brostrm with a Gould modication. In patients with excessive laxity, failed Brostrm, augmentation with an allograft semitendinosus or Achilles, or autograft hamstring tendon may be used. In addition, an arthroscopic evaluation is conducted before the incision to conrm the status of the joint, remove any synovial impingement, any bony impingement, loose bodies, and if necessary conrm the syndesmosis is intact.34 Antero-medial and anterolateral portals are used. The anterolateral portal is incorporated into the Brostrm incision anteriorly. Swelling from uid extravasation is present but usually of no impediment to identifying anatomy and carrying out the procedure. In general if there is any pain associated with the choric instability, arthroscopy is recommended at the time of stabilization to deal with any of the associated pathologies as noted earlier in the text (Fig. 8). Most commonly a modied Brostrm is performed as the procedure of choice, but a lateral reconstruction with autogenous or allograft transplantation can be used.

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21. Takao M, Innami K, Matsushita T, et al: Arthroscopic and magnetic resonance image appearance and reconstruction of the anterior talobular ligament in cases of apparent functional ankle instability. Am J Sports Med 36:1542-1547, 2008 22. Taga I, Shino K, Inoue M, et al: Cartilage lesions in ankles with lateral ligament injury. Am J Sports Med 21:120-127, 1993 23. Harrington KD: Degenerative arthritis of the ankle secondary to longstanding lateral ligament instability. J Bone Joint Surg Am 61:354-361, 1979 24. Choi WJ, Lee JW, Han SH, et al: Chronic lateral ankle instability: The effect of intra-articular lesions on clinical outcome. Am J Sports Med 36:2167-2172, 2008 25. Komenda GA, Ferkel RD: Arthroscopic ndings associated with the unstable ankle. Foot Ankle Int 20:708-713, 1999 26. Ferkel RD, Chams RN: Chronic lateral instability: Arthroscopic ndings and long term results. Foot Ankle Int 28:24-31, 2007 27. Okuda R, Kinoshita M, Morikawa J, et al: Arthroscopic ndings in chronic lateral ankle instability: Do focal chondral lesions inuence the results of ligament reconstruction? Am J Sports Med 33:35-42, 2005 28. Takao M, Komatsu F, Naito K, et al: Reconstruction of lateral ligament with arthroscopic drilling for treatment of early-stage osteoarthritis in unstable ankles. Arthroscopy 22:1119-1125, 2006 29. Lfvenberg R, Krrholm J, Ahlgren O: Ligament reconstruction for ankle instability. A 5-year prospective RSA follow-up of 30 cases. Acta Orthop Scand 65:401-407, 1994 30. van Dijk NC: Anterior and posterior ankle impingement. Foot Ankle Clin 11:663-683, 2006 31. Ferkel RD, Karzel RP, Del Pizzo W, et al: Arthroscopic treatment of anterolateral impingement of the ankle. Am J Sports Med 19:440-446, 1991 32. van Dijk CN, Kort N: Tendoscopy of the peroneal tendons. Arthroscopy 14:471-478, 1998 33. Lui TH: Endoscopic peroneal retinaculum reconstruction. Knee Surg Sports Traumatol Arthrosc 14:478-481, 2006 34. Amendola A, Petrik J, Webster-Bogaert S: Ankle arthroscopy: Outcome in 79 consecutive patients. Arthroscopy 12:565-573, 1996