Surgical management and clinical outcomes of repair for anterior talofibular ligament injury at talar attachment_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHENG Kaiwen ^1,2 , ZHANG Yuyan ^1,2 , YANG Hao ^1,2 , ZHANG Chenghao ^1,2 ,  LI Qi ^1,2

1. Sports Medicine Center, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China;
2. Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China;

Corresponding?author：

LI Qi, Email: liqi_sports@scu.edu.cn

Keywords：

Anterior talofibular ligament injury; talar attachment; avulsion fracture; ankle instability; arthroscopy

DOI：

10.7507/1002-1892.202601104

Video：

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Objective To investigate the surgical treatment methods and clinical outcomes of repair for anterior talofibular ligament (ATFL) injury at talar attachment. Methods A clinical data of 26 patients with ATFL injuries at the talar attachment, who underwent surgical treatment between January 2021 and January 2025, was retrospectively analyzed. The cohort comprised 12 males and 14 females, with a mean age of 30 years (range, 11-52 years). The mean body mass index was 21.5 kg/m² (range, 16.2-28.2 kg/m²). The median disease duration was 6 weeks (range, 4 days to 108 months). Preoperative Numeric Rating Scale (NRS) score was 4.5±1.7 and American Orthopaedic Foot and Ankle Society (AOFAS) score was 58.0±19.1. The anterior drawer test was positive in all cases, and the varus stress test was positive in two cases. Concomitant pathologies included osteochondral lesions of the talus (n=4), calcaneofibular ligament injury (n=2), sinus tarsi syndrome (n=3), and generalized ligamentous laxity (n=2). Arthroscopic repair was performed in 21 patients. Five patients with extensive ATFL avulsions or concomitant calcaneofibular ligament injuries underwent a mini-open procedure. Standardized postoperative rehabilitation was implemented for all patients. Results All incisions achieved primary healing with no surgery-related complication. All patients were followed up 12-59 months (mean, 28 months). At last follow-up, NRS and AOFAS scores improved significantly to 0.8±1.0 and 96.8±5.0, respectively (P<0.05). Mechanical stability was restored, with negative anterior drawer tests in all patients. Regarding functional recovery, 11 patients returned to their pre-injury sports intensity at a mean of 6 months (range, 4-7 months). The remaining 15 patients who had no exercise habits before injury resumed normal daily activities at 6 months after operation, among them, 2 cases exhibited limited range of motion at 6 months but achieved functional independence for daily activities following intensive rehabilitation. Conclusion Surgical repair of ATFL injury at the talar attachment—whether via arthroscopic suture anchors, mini-open suture anchors, or transosseous suturing—yields favorable clinical outcomes. The choice of surgical technique should be stratified by the extent of ligamentous injury and the severity of concomitant pathologies.

Citation： ZHENG Kaiwen, ZHANG Yuyan, YANG Hao, ZHANG Chenghao, LI Qi. Surgical management and clinical outcomes of repair for anterior talofibular ligament injury at talar attachment. Chinese Journal of Reparative and Reconstructive Surgery, 2026, 40(9): 1393-1398. doi: 10.7507/1002-1892.202601104 Copy

1.	Herzog MM, Kerr ZY, Marshall SW, et al. Epidemiology of ankle sprains and chronic ankle instability[J]. J Athl Train, 2019, 54(6): 603-610.
2.	Altomare D, Fusco G, Bertolino E, et al. Evidence-based treatment choices for acute lateral ankle sprain: A comprehensive systematic review[J]. Eur Rev Med Pharmacol Scie, 2022, 26(6): 1876-1884.
3.	Brostroem L. Sprained ankles. Ⅰ. Anatomic lesions in recent sprains[J]. Acta Chir Scand, 1964, 128: 483-495.
4.	侯輝歌, 胡大海, 肖磊, 等. 慢性踝關節不穩關節鏡下距腓前韌帶損傷的分型方案[J]. 暨南大學學報 (自然科學與醫學版), 2022, 43(2): 159-165.
5.	Tsai CS, Huang MT, Jou IM, et al. Arthroscopic modified Brostr?m may improve function while anatomic reconstructions could enhance stability for chronic lateral ankle instability: A network meta-analysis[J]. Foot Ankle Surg, 2024, 30(8): 630-642.
6.	Wittig U, Hohenberger G, Ornig M, et al. All-arthroscopic reconstruction of the anterior talofibular ligament is comparable to open reconstruction: a systematic review[J]. EFORT Open Rev, 2022, 7(1): 3-12.
7.	代勝, 馮萌, 毛根穩, 等. 開放與鏡下Brostr?m-Gould術修復距腓前韌帶的比較[J]. 中國矯形外科雜志, 2025, 33(16): 1477-1482.
8.	Feng SM, Sun QQ, Wang AG, et al. Long-term functional outcomes of all-inside arthroscopic repair of anterior talofibular ligament avulsion fracture[J]. Foot Ankle Surg, 2021, 27(2): 156-161.
9.	張珉源, 李愷泉, 楊鴻邁, 等. 關節鏡下距腓前韌帶損傷增強修復研究進展[J]. 中國修復重建外科雜志, 2025, 39(12): 1600-1605.
10.	K?se ?, Turan A, Acar B, et al. Avulsion fracture of anterior talofibular ligament from talus: A case report[J]. Foot (Edinb), 2019, 38: 24-29.
11.	曹廣超, 石榮劍, 李亮, 等. 手術治療距腓前韌帶距骨側止點撕脫骨折的療效觀察[J]. 中華解剖與臨床雜志, 2022, 27(9): 656-659.
12.	Xiong S, Xie X, Shi W, et al. Avulsion fracture is associated with more pain after anatomic repair procedure for ATFL injury at the talar side[J]. Knee Surg Sports Traumatol Arthrosc, 2023, 31(12): 6104-6112.
13.	Ueda N, Murahashi Y, Takahashi K, et al. All-inside arthroscopic anatomic anterior talofibular ligament repair for chronic lateral ankle instability and injury at the talar attachment: surgical technique[J/OL]. Arthrosc Tech, 2024, 13(11): 103098. doi: 10.1016/j.eats.2024.103098.
14.	陳守勃, 華英匯. 前距腓韌帶修復術治療踝關節外側不穩定療效分析[J]. 中國修復重建外科雜志, 2017, 31(4): 427-431.
15.	陳漢鑫, 趙廷虎, 岳志軍, 等. 全關節鏡下韌帶修補治療青少年慢性踝關節不穩的臨床療效觀察[J]. 足踝外科電子雜志, 2023, 10(2): 14-18.
16.	中華醫學會運動醫療分會足踝專業委員會, 中國醫師協會運動醫學醫師分會足踝學組. 慢性踝關節外側不穩手術治療專家共識[J]. 中華醫學雜志, 2021, 101(37): 2940-2946.
17.	Nunes GA, Martinez LM, Cordier G, et al. The ATFL inferior fascicle, the CFL and the PTFL have a continuous footprint at the medial side of the fibula[J]. Knee Surg Sports Traumatol Arthrosc, 2023, 31(11): 5207-5213.
18.	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[J]. Int Orthop, 2022, 46(12): 2821-2828.
19.	Takao M, Matsui K, Stone JW, et al. Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle[J]. Knee Surg Sports Traumatol Arthrosc, 2016, 24(4): 1003-1006.
20.	張語嫣, 楊好, 鄭凱文. 關節鏡下保留距腓前韌帶腓骨止點撕脫骨塊縫合修復距腓前韌帶損傷的臨床療效[J]. 中國修復重建外科雜志, 2026, 40(5): 752-757.
21.	Pearce CJ, Tourné Y, Zellers J, et al. Rehabilitation after anatomical ankle ligament repair or reconstruction[J]. Knee Surg Sports Traumatol Arthrosc, 2016, 24(4): 1130-1139.
22.	Teramoto A, Murahashi Y, Takahashi K, et al. Effect of accelerated rehabilitation on early return to sport after arthroscopic ankle lateral ligament repair[J/OL]. Orthop J Sports Med, 2022, 10(9): 23259671221121676. doi: 10.1177/23259671221121676.
23.	van den Bekerom MP, Oostra RJ, Golanó P, et al. The anatomy in relation to injury of the lateral collateral ligaments of the ankle: a current concepts review[J]. Clin Anat, 2008, 21(7): 619-626.
24.	Kumai T, Takakura Y, Rufai A, et al. The functional anatomy of the human anterior talofibular ligament in relation to ankle sprains[J]. J Anat, 2002, 200(5): 457-465.
25.	Miyamoto W, Takao M, Nishiguchi K, et al. Technique tip: a radiographic projection for an avulsion fracture of the talar attachment of the anterior talofibular ligament[J]. Foot Ankle Int, 2008, 29(4): 435-437.
26.	Sakurai S, Nakasa T, Ikuta Y, et al. Morphological characteristics of lateral ankle ligament injuries associated with recurrent instability after arthroscopic repair for chronic ankle instability: 3D volume rendering mri model analysis[J/OL]. Orthop J Sports Med, 2025, 13(11): 23259671251387340. doi: 10.1177/23259671251387340.
27.	Liu F, Pan H, Huang RK. All-arthroscopic repair of talar-sided anterior talofibular ligament insertion tears using knotless anchors: a retrospective case series[J/OL]. J Int Med Res, 2025, 53(12): 03000605251404782. doi: 10.1177/03000605251404782.
28.	Li H, Hua Y, Li H, et al. Anterior talofibular ligament (ATFL) repair using two suture anchors produced better functional outcomes than using one suture anchor for the treatment of chronic lateral ankle instability[J]. Knee Surg Sports Traumatol Arthrosc, 2020, 28(1): 221-226.
29.	Zhou YF, Zhang HZ, Zhang ZZ, et al. Comparison of function- and activity-related outcomes after anterior talofibular ligament repair with 1 versus 2 suture anchors[J/OL]. Orthop J Sports Med, 2021, 9(7): 2325967121991930. doi: 10.1177/2325967121991930.
30.	Feng S M, Shao C Q, Sun Q Q, et al. Functional outcomes of all-inside arthroscopic anterior talofibular ligament repair with loop suture versus free-edge suture[J/OL]. J Orthop Surg Res, 2022, 17(1): 502. doi: 10.1186/s13018-022-03402-z.

1. Herzog MM, Kerr ZY, Marshall SW, et al. Epidemiology of ankle sprains and chronic ankle instability[J]. J Athl Train, 2019, 54(6): 603-610.
2. Altomare D, Fusco G, Bertolino E, et al. Evidence-based treatment choices for acute lateral ankle sprain: A comprehensive systematic review[J]. Eur Rev Med Pharmacol Scie, 2022, 26(6): 1876-1884.
3. Brostroem L. Sprained ankles. Ⅰ. Anatomic lesions in recent sprains[J]. Acta Chir Scand, 1964, 128: 483-495.
4. 侯輝歌, 胡大海, 肖磊, 等. 慢性踝關節不穩關節鏡下距腓前韌帶損傷的分型方案[J]. 暨南大學學報 (自然科學與醫學版), 2022, 43(2): 159-165.
5. Tsai CS, Huang MT, Jou IM, et al. Arthroscopic modified Brostr?m may improve function while anatomic reconstructions could enhance stability for chronic lateral ankle instability: A network meta-analysis[J]. Foot Ankle Surg, 2024, 30(8): 630-642.
6. Wittig U, Hohenberger G, Ornig M, et al. All-arthroscopic reconstruction of the anterior talofibular ligament is comparable to open reconstruction: a systematic review[J]. EFORT Open Rev, 2022, 7(1): 3-12.
7. 代勝, 馮萌, 毛根穩, 等. 開放與鏡下Brostr?m-Gould術修復距腓前韌帶的比較[J]. 中國矯形外科雜志, 2025, 33(16): 1477-1482.
8. Feng SM, Sun QQ, Wang AG, et al. Long-term functional outcomes of all-inside arthroscopic repair of anterior talofibular ligament avulsion fracture[J]. Foot Ankle Surg, 2021, 27(2): 156-161.
9. 張珉源, 李愷泉, 楊鴻邁, 等. 關節鏡下距腓前韌帶損傷增強修復研究進展[J]. 中國修復重建外科雜志, 2025, 39(12): 1600-1605.
10. K?se ?, Turan A, Acar B, et al. Avulsion fracture of anterior talofibular ligament from talus: A case report[J]. Foot (Edinb), 2019, 38: 24-29.
11. 曹廣超, 石榮劍, 李亮, 等. 手術治療距腓前韌帶距骨側止點撕脫骨折的療效觀察[J]. 中華解剖與臨床雜志, 2022, 27(9): 656-659.
12. Xiong S, Xie X, Shi W, et al. Avulsion fracture is associated with more pain after anatomic repair procedure for ATFL injury at the talar side[J]. Knee Surg Sports Traumatol Arthrosc, 2023, 31(12): 6104-6112.
13. Ueda N, Murahashi Y, Takahashi K, et al. All-inside arthroscopic anatomic anterior talofibular ligament repair for chronic lateral ankle instability and injury at the talar attachment: surgical technique[J/OL]. Arthrosc Tech, 2024, 13(11): 103098. doi: 10.1016/j.eats.2024.103098.
14. 陳守勃, 華英匯. 前距腓韌帶修復術治療踝關節外側不穩定療效分析[J]. 中國修復重建外科雜志, 2017, 31(4): 427-431.
15. 陳漢鑫, 趙廷虎, 岳志軍, 等. 全關節鏡下韌帶修補治療青少年慢性踝關節不穩的臨床療效觀察[J]. 足踝外科電子雜志, 2023, 10(2): 14-18.
16. 中華醫學會運動醫療分會足踝專業委員會, 中國醫師協會運動醫學醫師分會足踝學組. 慢性踝關節外側不穩手術治療專家共識[J]. 中華醫學雜志, 2021, 101(37): 2940-2946.
17. Nunes GA, Martinez LM, Cordier G, et al. The ATFL inferior fascicle, the CFL and the PTFL have a continuous footprint at the medial side of the fibula[J]. Knee Surg Sports Traumatol Arthrosc, 2023, 31(11): 5207-5213.
18. 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[J]. Int Orthop, 2022, 46(12): 2821-2828.
19. Takao M, Matsui K, Stone JW, et al. Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle[J]. Knee Surg Sports Traumatol Arthrosc, 2016, 24(4): 1003-1006.
20. 張語嫣, 楊好, 鄭凱文. 關節鏡下保留距腓前韌帶腓骨止點撕脫骨塊縫合修復距腓前韌帶損傷的臨床療效[J]. 中國修復重建外科雜志, 2026, 40(5): 752-757.
21. Pearce CJ, Tourné Y, Zellers J, et al. Rehabilitation after anatomical ankle ligament repair or reconstruction[J]. Knee Surg Sports Traumatol Arthrosc, 2016, 24(4): 1130-1139.
22. Teramoto A, Murahashi Y, Takahashi K, et al. Effect of accelerated rehabilitation on early return to sport after arthroscopic ankle lateral ligament repair[J/OL]. Orthop J Sports Med, 2022, 10(9): 23259671221121676. doi: 10.1177/23259671221121676.
23. van den Bekerom MP, Oostra RJ, Golanó P, et al. The anatomy in relation to injury of the lateral collateral ligaments of the ankle: a current concepts review[J]. Clin Anat, 2008, 21(7): 619-626.
24. Kumai T, Takakura Y, Rufai A, et al. The functional anatomy of the human anterior talofibular ligament in relation to ankle sprains[J]. J Anat, 2002, 200(5): 457-465.
25. Miyamoto W, Takao M, Nishiguchi K, et al. Technique tip: a radiographic projection for an avulsion fracture of the talar attachment of the anterior talofibular ligament[J]. Foot Ankle Int, 2008, 29(4): 435-437.
26. Sakurai S, Nakasa T, Ikuta Y, et al. Morphological characteristics of lateral ankle ligament injuries associated with recurrent instability after arthroscopic repair for chronic ankle instability: 3D volume rendering mri model analysis[J/OL]. Orthop J Sports Med, 2025, 13(11): 23259671251387340. doi: 10.1177/23259671251387340.
27. Liu F, Pan H, Huang RK. All-arthroscopic repair of talar-sided anterior talofibular ligament insertion tears using knotless anchors: a retrospective case series[J/OL]. J Int Med Res, 2025, 53(12): 03000605251404782. doi: 10.1177/03000605251404782.
28. Li H, Hua Y, Li H, et al. Anterior talofibular ligament (ATFL) repair using two suture anchors produced better functional outcomes than using one suture anchor for the treatment of chronic lateral ankle instability[J]. Knee Surg Sports Traumatol Arthrosc, 2020, 28(1): 221-226.
29. Zhou YF, Zhang HZ, Zhang ZZ, et al. Comparison of function- and activity-related outcomes after anterior talofibular ligament repair with 1 versus 2 suture anchors[J/OL]. Orthop J Sports Med, 2021, 9(7): 2325967121991930. doi: 10.1177/2325967121991930.
30. Feng S M, Shao C Q, Sun Q Q, et al. Functional outcomes of all-inside arthroscopic anterior talofibular ligament repair with loop suture versus free-edge suture[J/OL]. J Orthop Surg Res, 2022, 17(1): 502. doi: 10.1186/s13018-022-03402-z.

Chinese Journal of Reparative and Reconstructive Surgery

Surgical management and clinical outcomes of repair for anterior talofibular ligament injury at talar attachment

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