*3.2.1 Suture repair*

examiner can often see a bare patch of the periosteum normally covered by ligament insertion on the medial or lateral malleolus. Many authors recommended a functional arthroscopic test, which includes axial traction to quantify the tibiotalar

*bald fibula (with kind permission of Thomas Bauer and the French Society of Arthroscopy [50]).*

*Arthroscopic classification of chronic ATFL injury. (a) Grade I, distended ATFL. (b) Grade II, avulsion from fibula with decreased tension. (c) Grade III, tear and thinning with no mechanical resistance. (d) Grade IV,*

Using visual inspection and probe testing, injury to the ATFL can be classified in

Grade 1, a distended ligament with normal thickness but decreased tension by

Grade 2, a fibular or talar avulsion (with fibrous tissue) of the ATFL, normal

Grade 4, which shows as scar tissue with no residual ligament and leaving a bald

The author also postulated different surgical strategies according to different grading. Surgical repair and reconstruction techniques are still under debate as will

Grade 3, a thin ATFL ligament with no mechanical resistance by hook

Grade 0, which represents a normal and continuous ligament with normal

opening, anterior drawer test, and varus and valgus tilt test [48, 49].

thickness, but decreased tension by hook palpation

palpation, with or without scar tissue

four grades (**Figure 6**) [50]:

*Essentials in Hip and Ankle*

**Figure 6.**

hook palpation

malleolus

be discussed later.

**90**

thickness and tautness

The Broström procedure is the gold standard for patients with CAI and comes with several modifications [24]. After exposure of the remnant ligaments, the ligaments are either folded (if elongated) or reattached (if detached) back to the distal fibula using suture anchors or transosseous sutures [54]. If the quality of the remnant ligament is poor or the quality of the repaired structure is unsatisfactory, the repair can be reinforced using the nearby inferior extensor retinaculum [55]. A complication of using inferior extensor retinaculum as augmentation is that it may cause a decrease in ankle plantarflexion or pain on plantarflexion after the surgery.

Osseous fragments in the lateral malleolar region should be removed if they cause pain or are detached. However, if the fragment size is large, removal may cause a considerable soft tissue defect, which may complicate later repair [56]. Therefore, screw fixation should be considered in cases of large-sized osseous fragments.

In patients with MAI, similar procedures are used to expose, fold, and reattach the remnant ligament to the medial malleolus. If the remnant tissue quality is poor, a periosteal flap reflected from medial malleolus can be used as augmentation. The key to repair the deltoid ligament is, first, to tie the sutures with the ankle in plantigrade position and, second, to avoid sutures through the deep and superficial deltoid ligaments [27]. Sutures across both layers of deltoid ligament may cause a decrease in ankle plantarflexion or pain on plantarflexion after the surgery.

Techniques for arthroscopy-assisted or all-inside repair of both medial and lateral ankle ligaments have been proposed over many years (**Figure 7**) [57–59]. In a recent review, the postoperative functional scores, patient's satisfaction, and surgery-related complications of open and arthroscopic lateral ankle ligament repair
