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Systematic review
Fair evidence consistently supports open surgical treatment for chronic ankle instability: a systematic review
  1. Chad Alexander Purcell1,
  2. James Calder2,3,
  3. Kentaro Matsui4,
  4. Pontus Andersson5,
  5. Jón Karlsson6,
  6. ESSKA AFAS Ankle Instability Group,
  7. Mark A Glazebrook7
    1. 1 Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada
    2. 2 Orthopaedic Surgery, Fortius Clinic, London, UK
    3. 3 Musculoskeletal Engineering, Imperial College London, London, UK
    4. 4 Department of Orthopaedic Surgery, Teikyo University, Tokyo, Japan
    5. 5 Gothenburg, Sweden
    6. 6 Department of Orthopaedics, University of Gothenburg, Gothenburg, Sweden
    7. 7 Department of Surgery, Orthopaedic Division, Dalhousie University, Halifax, Nova Scotia, Canada
    1. Correspondence to Chad Alexander Purcell; chad.purcell{at}


    Importance Patients with chronic ankle instability (CAI) who have failed non-operative treatments are most commonly treated with open ankle repair or reconstruction of the anterior talofibular ligament and/or calcaneofibular ligament. Over 50 operative techniques have been described for the treatment of CAI. However, there is no current systematic evaluation of currently used open operative techniques for the treatment of CAI.

    Aim/Objective The primary objective of this study is to provide evidence-based treatment recommendations for CAI in adults based on a comprehensive systematic review of the literature.

    Evidence review The literature review of PubMed, EMBASE, Cochrane and Web of Science databases was completed on 22 February 2017. Search terms included two concepts: lateral ligament of the ankle (patients) and open reconstructive or repair procedures (intervention). All published clinical studies with English translation were included. Biomechanical, cadaveric, review articles, minimally invasive procedures and arthroscopic procedures were excluded. Open operative procedures from included articles were classified as anatomical or non-anatomical and repair or reconstructive. Articles were then assigned a level of evidence (I-V) to denote quality of the research methods. Articles were reviewed collectively to provide a grade of recommendation (A-C or I) in support for or against the operative intervention in treatment of CAI.

    Findings Seventy one of 1635 identified articles were included for review. There is fair evidence (Grade B) in support of anatomical repair, anatomical reconstruction and non-anatomical reconstruction procedures. There was insufficient evidence available to grade internal brace and non-anatomical repair procedures.

    Conclusions and relevance Although only fair-quality evidence exists in support of open operative treatment of CAI, this systematic review helps reassure clinicians of their current practices. The literature reaffirms support for open anatomical repair and anatomical reconstruction technique for CAI.

    Level of evidence Level II, systematic review.

    • ankle
    • instability
    • repair / reconstruction
    • ligament
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    • Contributors CP, KM and MG have made substantial contributions to conception and design, acquisition or analysis and interpretation of data. JC and CP were responsible for drafting the manuscript and revising it critically based on feedback from MG and JC. MG has given final approval of the version to be published. All authors read and approved the final manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Collaborators Jorge Acevedo, Jorge Batista, Thomas Bauer, James Calder, Woo Jin Choi, Christopher DiGiovanni, Ali Ghorbani, Mark Glazebrook, Stéphane Guillo, Siu Wah Kong, Jon Karlsson, Jin Woo Lee, Peter G. Mangone, Kentaro Matsui, Frederick Michels, Andy Molloy, Caio Nery, Xavier Martin Olivia, Satoru Ozeki, Christopher Pearce, Anthony Perera, Hélder Pereira, Bas Pijnenburg, Fernando Raduan, James W. Stone, Masato Takao, Yves Tourné, Jordi Vega.

    • Patient consent for publication Not required.

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