Research progress on augmentation repair of anterior talofibular ligament under arthroscopy_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Minyuan , LI Kaiqaun , YANG Hongmai ,  LI Yanlin

Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China;

Corresponding author：

LI Yanlin, Email: 852387873@qq.com

Keywords：

Anterior talofibular ligament injury; augmentation repair; arthroscopy; research progress

DOI：

10.7507/1002-1892.202508042

Video：

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Objective To summarize the on augmentation repair of anterior talofibular ligament (ATFL) under arthroscopy. Methods The domestic and international studies from the past decade on augmentation techniques for the ATFL. The advantages and limitations of each approach were summarized and the outcomes of these augmentation techniques when applied to ATFL repair were evaluated. Results Mechanical augmentation techniques (suture tape or internal brace technology, double anchor enhancement technology) can increase the strength after ATFL repair, but it will increase the economic burden of the patients; bioenhanced repair technology (inferior extensor retinaculum enhancement, anterior tibiofibular ligament’s distal fascicle transfer augmentation) can also increase the strength after ATFL repair, but it will damage the anatomical structure in the ankle cavity to a certain extent, and the surgery is difficult, and the operation time will prolong and also increase the incidence of perioperative complications. Regardless of the augmentation techniques used, the benefits are higher for patients with high exercise needs, and active postoperative rehabilitation is required to maximize the surgical effect. Conclusion Although augmentation repair of ATFL offers several advantages, its use—whether augmentation should be employed and, if so, which technique is preferable—requires further study across patient subgroups owing to increased costs, potential disruption of ankle anatomy, and longer operation time.

1.	Lynch SA, Renström PA. Treatment of acute lateral ankle ligament rupture in the athlete. Conservative versus surgical treatment. Sports Med, 1999, 27(1): 61-71.
2.	Delahunt E, Bleakley CM, Bossard DS, et al. Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium. Br J Sports Med, 2018, 52(20): 1304-1310.
3.	Li D, Tang Q, Liu Q, et al. Arthroscopic anterior talofibular ligament repair with Internal Brace and lasso-loop technique for chronic ankle lateral instability. Int Orthop, 2022, 46(12): 2821-2828.
4.	Hopper GP, Benson DM, Wilson WT, et al. Anterior talofibular ligament repair with suture tape augmentation. Arthrosc Tech, 2020, 9(12): e1893-e1897.
5.	Qu F, Ji L, Sun C, et al. Arthroscopic anterior talofibular ligament repair combined with all-inside suture tape augmentation for treatment of chronic lateral ankle instability with generalized joint laxity. Foot Ankle Int, 2024, 45(10): 1102-1110.
6.	Hattori S, Onishi K, Chan CK, et al. Ultrasound-guided anterior talofibular ligament repair with augmentation can restore ankle kinematics: a cadaveric biomechanical study. Orthop J Sports Med, 2022, 10(8): 23259671221111397. doi: 10.1177/23259671221111397.
7.	Broström L. Sprained ankles. Ⅵ. Surgical treatment of chronic ligament ruptures. Acta Chir Scand, 1966, 132(5): 551-565.
8.	Gould N, Seligson D, Gassman J. Early and late repair of lateral ligament of the ankle. Foot Ankle, 1980, 1(2): 84-89.
9.	Wittig U, Hohenberger G, Ornig M, et al. All-arthroscopic reconstruction of the anterior talofibular ligament is comparable to open reconstruction: a systematic review. EFORT Open Rev, 2022, 7(1): 3-12.
10.	Martin KD, Andres NN, Robinson WH. Suture tape augmented Broström procedure and early accelerated rehabilitation. Foot Ankle Int, 2021, 42(2): 145-150.
11.	Zhang ZQ, Lin YZ, Liu SY, et al. Comparison of the efficacy of the modified internal brace and the arthroscopic Broström-Gould procedure for chronic lateral ankle instability. Int Orthop, 2025, 49(3): 713-720.
12.	Sethi M, Limaye R, Rai A, et al. Anterior talo-fibular ligament reconstruction with InternalBrace™ for chronic lateral ankle instability in pediatric patients. Cureus, 2023, 15(9): e44979. doi: 10.7759/cureus.44979.
13.	Wenzel-Schwarz F, Wittig U, Nemecek E, et al. Broström ankle ligament repair augmented with suture tape: Results of magnetic resonance imaging evaluation. Wien Klin Wochenschr, 2024, 136(19-20): 562-569.
14.	Comfort SM, Marchetti DC, Duncan PP, et al. Broström repair with and without augmentation: comparison of outcomes at median follow-up of 5 years. Foot Ankle Int, 2023, 44(8): 691-701.
15.	Mercer NP, Azam MT, Davalos N, et al. Anterior talofibular ligament augmentation with internal brace in the office setting. Arthroscopy Techniques, 2022, 11(4): e545-e550.
16.	Fan D, Liu X, Zhang L. Single anchor versus double anchor for arthroscopic anterior talofibular ligament repair: A systematic review and mate-analysis of cohort studies. J Orthop Surg (Hong Kong), 2023, 31(3): 10225536231217914. doi: 10.1177/10225536231217914.
17.	Xiao L, Zheng B, Zhou Y, et al. Biomechanical study of arthroscopic all-inside anterior talofibular ligament suture augmentation repair, plus suture augmentation repair and anterior tibiofibular ligament's distal fascicle transfer augmentation repair. J Clin Med, 2022, 11(17): 5235. doi: 10.3390/jcm11175235.
18.	Feng SM, Sun QQ, Chen J, et al. One double-loaded suture anchor is sufficient for all-inside arthroscopic anterior talofibular ligament repair. Knee Surg Sports Traumatol Arthrosc, 2023, 31(8): 3500-3508.
19.	Takao M, Matsui K, Stone JW, et al. Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle. Knee Surg Sports Traumatol Arthrosc, 2016, 24(4): 1003-1006.
20.	Qin J, Fu Q, Zhou Q, et al. Fully intra-articular Lasso-Loop stitch technique for arthroscopic anterior talofibular ligament repair. Foot Ankle Int, 2022, 43(3): 439-447.
21.	Guo H, Chen B, Chen Z, et al. The lasso-loop technique is equivalent to the simple suture technique in arthroscopic anterior talofibular ligament repair. Knee Surg Sports Traumatol Arthrosc, 2023, 31(6): 2174-2182.
22.	Chen Z, Xue X, Li Q, et al. Outcomes of a novel all-inside arthroscopic anterior talofibular ligament repair for chronic ankle instability. Int Orthop, 2023, 47(4): 995-1003.
23.	Yang Y, Han J, Wu H, et al. Arthro-Broström with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques. BMC Musculoskelet Disord, 2022, 23(1): 795. doi: 10.1186/s12891-022-05709-8.
24.	Luo X, Xue C, Xue Y, et al. Augmentation with the inferior extensor retinaculum may facilitate earlier recovery in all-inside arthroscopic management of chronic lateral ankle instability. J Orthop Surg Res, 2025, 20(1): 40. doi: 10.1186/s13018-024-05437-w.
25.	Yao X, Liang X, Mu Y, et al. Simplified arthroscopic anterior talofibular ligament repair with inferior extensor retinaculum reinforcement: technical notes and preliminary results. J Orthop Surg Res, 2024, 19(1): 573. doi: 10.1186/s13018-024-05067-2.
26.	Jo J, Lee JW, Kim HJ, et al. Arthroscopic all-inside anterior talofibular ligament repair with and without inferior extensor retinacular reinforcement: A prospective randomized study. J Bone Joint Surg (Am), 2021, 103(17): 1578-1587.
27.	Lee SH, Cho HG, Yang JH. Additional inferior extensor retinaculum augmentation after all-inside arthroscopic anterior talofibular ligament repair for chronic ankle instability is not necessary. Am J Sports Med, 2021, 49(7): 1721-1731.
28.	Murray B, Ghasemi A, Memon R, et al. Outcomes of adding inferior extensor retinaculum reinforcement to arthroscopic anterior talofibular ligament repair: a systematic review and meta-analysis. Foot Ankle Int, 2025, 46(7): 794-805.
29.	Shan L, Zhao B, Wang H, et al. Comparison of inferior extensor retinacular reinforcement versus nonreinforcement in arthroscopic isolated anterior talofibular ligament repair for chronic lateral ankle instability: a systematic review and meta-analysis. Orthop J Sports Med, 2024, 12(12): 23259671241270305. doi: 10.1177/23259671241270305.
30.	Zhang L, Wang R, Yang S, et al. Anterior talofibular ligament repair in combination with anterior tibiofibular ligament distal fascicle transfer for the treatment of chronic lateral ankle instability: a finite element analysis. J Foot Ankle Surg, 2024, 63(4): 435-442.
31.	Wang R, Yang Y, You G, et al. Chronic lateral ankle instability using anterior tibiofibular ligament distal fascicle transfer augmentation repair: an anatomical, biomechanical, and histological study. Front Bioeng Biotechnol, 2024, 12: 1326036. doi: 10.3389/fbioe.2024.1326036.
32.	Vega J, Poggio D, Heyrani N, et al. Arthroscopic all-inside ATiFL's distal fascicle transfer for ATFL's superior fascicle reconstruction or biological augmentation of lateral ligament repair. Knee Surg Sports Traumatol Arthrosc, 2020, 28(1): 70-78.
33.	Tian J, Mok TN, Sin TH, et al. Clinical outcomes of anterior tibiofibular ligament's distal fascicle transfer versus ligament reconstruction with InternalBrace™ for chronic ankle instability patients. Arch Orthop Trauma Surg, 2022, 142(10): 2829-2837.
34.	Xiang D, Jin W, Li H, et al. Biomechanical improvement of anterior talofibular ligament by augmentation repair of ligament advance reinforcement system: a cadaver study. BMC Surg, 2023, 23(1): 307. doi: 10.1186/s12893-023-02136-x.
35.	Matsui K, Takao M, Tochigi Y, et al. Anatomy of anterior talofibular ligament and calcaneofibular ligament for minimally invasive surgery: a systematic review. Knee Surg Sports Traumatol Arthrosc, 2017, 25(6): 1892-1902.
36.	Hu D, Wang N, Wang H, et al. Clinical outcomes of arthroscopic all-inside anterior talofibular ligament suture augmentation repair versus modified suture augmentation repair for chronic ankle instability patients. BMC Musculoskelet Disord, 2024, 25(1): 48. doi: 10.1186/s12891-023-07085-3.
37.	Hu D, Xie P, Zheng B, et al. Clinical outcomes of arthroscopic all-inside anterior talofibular ligament trans- augmentation repair versus modified trans- augmentation repair for patients with chronic ankle instability. J Orthop Surg Res, 2025, 20(1): 168. doi: 10.1186/s13018-025-05559-9.
38.	Chen Z, Zhao Y, Xue X, et al. Outcomes comparison of elastic bandage versus lower-leg cast immobilization after anterior talofibular ligament repair. BMC Musculoskelet Disord, 2024, 25(1): 469. doi: 10.1186/s12891-024-07584-x.
39.	Hunt KJ, Hewitt MA, Buckley SE, et al. Ligament augmentation repair is broadly applied across different orthopaedic subspecialities: an ISAKOS international survey of orthopaedic surgeons. J ISAKOS, 2023, 8(4): 239-245.

1. Lynch SA, Renström PA. Treatment of acute lateral ankle ligament rupture in the athlete. Conservative versus surgical treatment. Sports Med, 1999, 27(1): 61-71.
2. Delahunt E, Bleakley CM, Bossard DS, et al. Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium. Br J Sports Med, 2018, 52(20): 1304-1310.
3. Li D, Tang Q, Liu Q, et al. Arthroscopic anterior talofibular ligament repair with Internal Brace and lasso-loop technique for chronic ankle lateral instability. Int Orthop, 2022, 46(12): 2821-2828.
4. Hopper GP, Benson DM, Wilson WT, et al. Anterior talofibular ligament repair with suture tape augmentation. Arthrosc Tech, 2020, 9(12): e1893-e1897.
5. Qu F, Ji L, Sun C, et al. Arthroscopic anterior talofibular ligament repair combined with all-inside suture tape augmentation for treatment of chronic lateral ankle instability with generalized joint laxity. Foot Ankle Int, 2024, 45(10): 1102-1110.
6. Hattori S, Onishi K, Chan CK, et al. Ultrasound-guided anterior talofibular ligament repair with augmentation can restore ankle kinematics: a cadaveric biomechanical study. Orthop J Sports Med, 2022, 10(8): 23259671221111397. doi: 10.1177/23259671221111397.
7. Broström L. Sprained ankles. Ⅵ. Surgical treatment of chronic ligament ruptures. Acta Chir Scand, 1966, 132(5): 551-565.
8. Gould N, Seligson D, Gassman J. Early and late repair of lateral ligament of the ankle. Foot Ankle, 1980, 1(2): 84-89.
9. Wittig U, Hohenberger G, Ornig M, et al. All-arthroscopic reconstruction of the anterior talofibular ligament is comparable to open reconstruction: a systematic review. EFORT Open Rev, 2022, 7(1): 3-12.
10. Martin KD, Andres NN, Robinson WH. Suture tape augmented Broström procedure and early accelerated rehabilitation. Foot Ankle Int, 2021, 42(2): 145-150.
11. Zhang ZQ, Lin YZ, Liu SY, et al. Comparison of the efficacy of the modified internal brace and the arthroscopic Broström-Gould procedure for chronic lateral ankle instability. Int Orthop, 2025, 49(3): 713-720.
12. Sethi M, Limaye R, Rai A, et al. Anterior talo-fibular ligament reconstruction with InternalBrace™ for chronic lateral ankle instability in pediatric patients. Cureus, 2023, 15(9): e44979. doi: 10.7759/cureus.44979.
13. Wenzel-Schwarz F, Wittig U, Nemecek E, et al. Broström ankle ligament repair augmented with suture tape: Results of magnetic resonance imaging evaluation. Wien Klin Wochenschr, 2024, 136(19-20): 562-569.
14. Comfort SM, Marchetti DC, Duncan PP, et al. Broström repair with and without augmentation: comparison of outcomes at median follow-up of 5 years. Foot Ankle Int, 2023, 44(8): 691-701.
15. Mercer NP, Azam MT, Davalos N, et al. Anterior talofibular ligament augmentation with internal brace in the office setting. Arthroscopy Techniques, 2022, 11(4): e545-e550.
16. Fan D, Liu X, Zhang L. Single anchor versus double anchor for arthroscopic anterior talofibular ligament repair: A systematic review and mate-analysis of cohort studies. J Orthop Surg (Hong Kong), 2023, 31(3): 10225536231217914. doi: 10.1177/10225536231217914.
17. Xiao L, Zheng B, Zhou Y, et al. Biomechanical study of arthroscopic all-inside anterior talofibular ligament suture augmentation repair, plus suture augmentation repair and anterior tibiofibular ligament's distal fascicle transfer augmentation repair. J Clin Med, 2022, 11(17): 5235. doi: 10.3390/jcm11175235.
18. Feng SM, Sun QQ, Chen J, et al. One double-loaded suture anchor is sufficient for all-inside arthroscopic anterior talofibular ligament repair. Knee Surg Sports Traumatol Arthrosc, 2023, 31(8): 3500-3508.
19. Takao M, Matsui K, Stone JW, et al. Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle. Knee Surg Sports Traumatol Arthrosc, 2016, 24(4): 1003-1006.
20. Qin J, Fu Q, Zhou Q, et al. Fully intra-articular Lasso-Loop stitch technique for arthroscopic anterior talofibular ligament repair. Foot Ankle Int, 2022, 43(3): 439-447.
21. Guo H, Chen B, Chen Z, et al. The lasso-loop technique is equivalent to the simple suture technique in arthroscopic anterior talofibular ligament repair. Knee Surg Sports Traumatol Arthrosc, 2023, 31(6): 2174-2182.
22. Chen Z, Xue X, Li Q, et al. Outcomes of a novel all-inside arthroscopic anterior talofibular ligament repair for chronic ankle instability. Int Orthop, 2023, 47(4): 995-1003.
23. Yang Y, Han J, Wu H, et al. Arthro-Broström with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques. BMC Musculoskelet Disord, 2022, 23(1): 795. doi: 10.1186/s12891-022-05709-8.
24. Luo X, Xue C, Xue Y, et al. Augmentation with the inferior extensor retinaculum may facilitate earlier recovery in all-inside arthroscopic management of chronic lateral ankle instability. J Orthop Surg Res, 2025, 20(1): 40. doi: 10.1186/s13018-024-05437-w.
25. Yao X, Liang X, Mu Y, et al. Simplified arthroscopic anterior talofibular ligament repair with inferior extensor retinaculum reinforcement: technical notes and preliminary results. J Orthop Surg Res, 2024, 19(1): 573. doi: 10.1186/s13018-024-05067-2.
26. Jo J, Lee JW, Kim HJ, et al. Arthroscopic all-inside anterior talofibular ligament repair with and without inferior extensor retinacular reinforcement: A prospective randomized study. J Bone Joint Surg (Am), 2021, 103(17): 1578-1587.
27. Lee SH, Cho HG, Yang JH. Additional inferior extensor retinaculum augmentation after all-inside arthroscopic anterior talofibular ligament repair for chronic ankle instability is not necessary. Am J Sports Med, 2021, 49(7): 1721-1731.
28. Murray B, Ghasemi A, Memon R, et al. Outcomes of adding inferior extensor retinaculum reinforcement to arthroscopic anterior talofibular ligament repair: a systematic review and meta-analysis. Foot Ankle Int, 2025, 46(7): 794-805.
29. Shan L, Zhao B, Wang H, et al. Comparison of inferior extensor retinacular reinforcement versus nonreinforcement in arthroscopic isolated anterior talofibular ligament repair for chronic lateral ankle instability: a systematic review and meta-analysis. Orthop J Sports Med, 2024, 12(12): 23259671241270305. doi: 10.1177/23259671241270305.
30. Zhang L, Wang R, Yang S, et al. Anterior talofibular ligament repair in combination with anterior tibiofibular ligament distal fascicle transfer for the treatment of chronic lateral ankle instability: a finite element analysis. J Foot Ankle Surg, 2024, 63(4): 435-442.
31. Wang R, Yang Y, You G, et al. Chronic lateral ankle instability using anterior tibiofibular ligament distal fascicle transfer augmentation repair: an anatomical, biomechanical, and histological study. Front Bioeng Biotechnol, 2024, 12: 1326036. doi: 10.3389/fbioe.2024.1326036.
32. Vega J, Poggio D, Heyrani N, et al. Arthroscopic all-inside ATiFL's distal fascicle transfer for ATFL's superior fascicle reconstruction or biological augmentation of lateral ligament repair. Knee Surg Sports Traumatol Arthrosc, 2020, 28(1): 70-78.
33. Tian J, Mok TN, Sin TH, et al. Clinical outcomes of anterior tibiofibular ligament's distal fascicle transfer versus ligament reconstruction with InternalBrace™ for chronic ankle instability patients. Arch Orthop Trauma Surg, 2022, 142(10): 2829-2837.
34. Xiang D, Jin W, Li H, et al. Biomechanical improvement of anterior talofibular ligament by augmentation repair of ligament advance reinforcement system: a cadaver study. BMC Surg, 2023, 23(1): 307. doi: 10.1186/s12893-023-02136-x.
35. Matsui K, Takao M, Tochigi Y, et al. Anatomy of anterior talofibular ligament and calcaneofibular ligament for minimally invasive surgery: a systematic review. Knee Surg Sports Traumatol Arthrosc, 2017, 25(6): 1892-1902.
36. Hu D, Wang N, Wang H, et al. Clinical outcomes of arthroscopic all-inside anterior talofibular ligament suture augmentation repair versus modified suture augmentation repair for chronic ankle instability patients. BMC Musculoskelet Disord, 2024, 25(1): 48. doi: 10.1186/s12891-023-07085-3.
37. Hu D, Xie P, Zheng B, et al. Clinical outcomes of arthroscopic all-inside anterior talofibular ligament trans- augmentation repair versus modified trans- augmentation repair for patients with chronic ankle instability. J Orthop Surg Res, 2025, 20(1): 168. doi: 10.1186/s13018-025-05559-9.
38. Chen Z, Zhao Y, Xue X, et al. Outcomes comparison of elastic bandage versus lower-leg cast immobilization after anterior talofibular ligament repair. BMC Musculoskelet Disord, 2024, 25(1): 469. doi: 10.1186/s12891-024-07584-x.
39. Hunt KJ, Hewitt MA, Buckley SE, et al. Ligament augmentation repair is broadly applied across different orthopaedic subspecialities: an ISAKOS international survey of orthopaedic surgeons. J ISAKOS, 2023, 8(4): 239-245.

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