No Difference Between Open and Arthroscopic ATFL Repair, Both Yielding Clinically Significant Improvement in Chronic Ankle Instability: A Randomized Controlled Trial

Background: Lateral ligament repair is a reliable surgical approach for the treatment of chronic ankle instability (CAI). Although the open technique has shown success over time, technological advancements have enabled the increasing use of arthroscopic techniques, with the expectation of improving results. The objective of the current trial was to compare the results of open and arthroscopic anterior talofibular ligament (ATFL) repair in patients with CAI. Hypothesis: Arthroscopic anatomic repair would lead to superior functional outcome as measured by the Foot and Ankle Outcome Score (FAOS) compared with open anatomic repair. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Patients at 6 participating sites were included if they were age 16 years or older, had a history of ankle inversion sprain, had symptoms ≥6 months, and had mechanical ankle instability. Randomization was performed over open and arthroscopic ATFL repair, with or without retinacular augmentation. Both procedures were performed using all-suture anchors and corresponding instrumentation. The primary outcome measure was functional outcome as measured by the FAOS at 24 months of follow-up. Results: A total of 41 patients were included: 21 patients in the open repair group and 20 patients in the arthroscopic repair group. The mean ± SD age of the patients at the time of surgery was 32 ± 13 years. No statistically significant difference was found between treatment groups for any of the FAOS subscales at any of the follow-up intervals. Both groups showed statistically significant score improvements across all FAOS subscales (P < .005). Complications were reported in 4 patients (18%) in the open surgery group (infection, swelling, deep venous thrombosis, adhesion) and 1 patient (5%) in the arthroscopy group (neurogenic pain) (P = .343). In both groups, 1 resprain was reported (5%). Conclusion: Open and arthroscopic ATFL repairs equally achieved statistically significant improvement in functional outcome and effectively addressed functional and mechanical ankle instability. Registration: ClinicalTrials.gov database (reference NCT02998333) and the Dutch trial registry (NL55707.018.16).