Journal of Clinical Orthopaedics and Trauma 43 (2023) 102227

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Journal of Clinical Orthopaedics and Trauma

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Return to sports after ankle reconstruction with tendon grafts in

chronic lateral ankle instability: A systematic review and meta-
analysis
Balgovind S. Raja a, Aditya K.S. Gowda a, Saroj Kumar Bhagat a, Watson Thomas b,
Pradeep Kumar Meena a, *
a
Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
b
Department of Orthopaedics, Department of Atomic Energy Hospital, Kalpakkam, India

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Anatomic reconstruction using grafts is being performed more frequently in athletes experi-
Received 6 July 2022 encing recurrent chronic lateral ankle instability (CLAI). The purpose of the study was to systematically
Received in revised form review the current literature to determine the rates of return to sports (RTS) along with timing in pa-
2 April 2023
tients with CLAI undergoing ligament reconstruction.
Accepted 13 July 2023
Available online 27 July 2023
Methods: The databases PubMed, Scopus, Cochrane, and Embase were searched based on the PRISMA
(Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Articles quoting on
the return to sports rate after lateral ankle reconstruction were included. The rates of return to any
Keywords:
Chronic lateral ankle instability
sports, return to pre-injury sports, and return to competitive sports along with the timing of return were
Return to sports evaluated and a proportion meta-analysis was performed.
Timeline Results: A total of 720 patients in 20 studies met our inclusion criteria. The RTS rates for any sports were
Anatomic reconstruction 95.3%, and 84.3% for pre-injury sports The average time taken for return to sports was 17 weeks. Post-
operative functional outcomes, ankle stability, and ROM were significantly improved in comparison to
preoperative status.
Conclusion: The RTS rates following lateral ankle reconstruction in CLAI showed a high return to any
sports, but moderate to high rates for the pre-injury or competitive level of sports.
Level of evidence: Level of evidence II.
© 2023 Delhi Orthopedic Association. All rights reserved.

1. Introduction
Over the decades ankle sprain injuries remain the most com-
mon ligament injuries seen in sports with an incidence of 4e7% of
the cases attended on an average in emergency department
consultation.1 Chronic lateral ankle instability (CLAI) often is seen
in about 40% of these individuals with lateral ligament injury
limiting them from sports or even daily activities.2 Multiple tech-
niques have been introduced for efficient treatment in CLAI
including various anatomical and non-anatomical procedures.
Surgical ankle stabilization techniques can be roughly classified
into two groups mainly repair involving the retensioning and su-
turing of the anterior talofibular ligament and the calcaneofibular
* Corresponding author.
E-mail address: pradeep.orth@aiimsrishikesh.edu.in (P.K. Meena).
ligament and reconstruction using tendon graft. The ankle lateral
ligament reconstruction aims to reconstruct the anterior talofibular
ligament (ATFL) alone or in combination with the calcaneofibular
ligament (CFL).3,4 The reconstruction procedures with grafts are
now being performed even as primary surgery in CLAI. A greater
number of patients, including younger ones or the athletic popu-
lation, have higher expectations from the surgery.5
Although there are quite a number studies describing lateral
ankle reconstruction in patients with CLAI, but the literature on
their clinical utility to regain preoperative functionality and return
to sports activity is limited. Even more, the information regarding
the return to pre-injury sports following reconstruction with grafts
in CLAI is scarce. The current evidence suggests equivalent short-
term functional outcomes of open or arthroscopic repair, open or
arthroscopic reconstruction, or autograft vs allograft.6 The best
available evidence for the success rates often comes from patients'
subjective assessment rather than the objective outcomes

https://doi.org/10.1016/j.jcot.2023.102227
0976-5662/© 2023 Delhi Orthopedic Association. All rights reserved.

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B.S. Raja, A.K.S. Gowda, S.K. Bhagat et al.
assessment. The return to sports rate offers a valid option of
assessing the outcome of the surgery, wherein every patient desires
to return to the pre-injury or even competitive level of sports after
an injury. The current systematic reviews which assess the evi-
dence in reconstruction procedures for CLAI have rarely quoted the
return to sports rate.7e10 Li et al. in their systematic review
mentioned 3 articles on RTS data.9 Teixeira et al. in their systematic
review has extensively explained various techniques used to repair
or reconstruct lateral ankle ligaments in patients with chronic
ankle instability to avoid/delay the natural evolution to ankle
arthritis but failed to mention the return to sports.10 The purpose of
our current study is to systematically analyze the evidence in the
literature on the return to sports rate following reconstruction
using grafts in CLAI. The current study offers itself as a valuable tool
for inpatient counseling.
2. Methods
2.1. Search strategy
The study was conducted following the PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses)
guidelines.11 The systematic search was conducted by the first
(B.S.R.) and the second (A.K.S.G.) authors in the databases: PubMed,
Scopus, Cochrane, and LILACS over 1 month (April 2021). The da-
tabases were searched from the date of inception till April 30, 2021
using the keywords ‘CLAI’, ’chronic lateral ankle injury(s)’, ‘ath-
letes’, ’sports' ‘return to sport’ ’recovery’’ ‘anatomical reconstruc-
tion’, ’endoscopic reconstruction’, ‘all inside reconstruction’,
Figure-1. Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) chart
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Journal of Clinical Orthopaedics and Trauma 43 (2023) 102227
‘allograft’, ‘autograft’, ‘graft’, ‘ankle instability’, ‘return to activity,
‘function’ and ‘rehabilitation’ using Boolean operators ‘AND’ and
‘OR’. The titles and abstracts were thoroughly looked at and the full
text of selected articles was searched using the selection criteria
mentioned below. Any disagreements between the authors were
discussed and the senior author (P.K.M.) took the final decision.
2.2. Eligibility criteria
The inclusion criteria included: (1) Clinical studies with data on
return to sports (in percentage or proportions) or return to sports
timeline following reconstruction in CLAI, (2) English language, and
(3) Published in a peer-reviewed journal. All the studies reporting
on the return to sports outcome irrespective of the types of grafts
used were included in the study. The exclusion criteria included: (1)
Reviews, Letter to editors, Cadaveric studies, biomechanical studies
or animal studies (2) Non-availability of full text, (3) Case reports
and case series with less than 3 patients.
2.3. Data extraction and analysis
Two authors (S.K.B and W.T) extracted the data from the
selected articles using a predetermined datasheet after the final list
was made. The data extracted included 1) Authors, Journal and
location of study, (2) study design and level of evidence, (3) Sample
size and gender characteristics (4) Return to sports data (percent-
age or proportions) or timeline, (5) Clinical outcomes (AOFAS, VAS,
Karlsson score), (6) follow-up period and (7) surgery details. Any
disagreements between the authors were discussed and the final
B.S. Raja, A.K.S. Gowda, S.K. Bhagat et al. Journal of Clinical Orthopaedics and Trauma 43 (2023) 102227

Table-1

Author Sample size, M/ Age, M/F Athletes Study design Follow up RTS data RTS timeline RTS parameter MINORS
(year) F score21

Allegra 11 33.3, 7/4 NS Retrospective 24.6 (23 11/11 return to NS Return to preinjury 12
20201 e27) m preinjury level level
Sigonney 57 (59 ankles) NS, 30/27 Yes Retrospective 3.0 (2.5; 3.7) 50/57 return to any NS ALR-RSI scale 12
202020 years sports
24/57 return to
preinjury
Lan S 15 31.9, 14/1 Yes Prospective 19.5 (18 15/15 return to NS Return to preinjury 13
202012 e24) m preinjury sports sports
Cordier 53 (54 ankles) 38.1, 34/16 Yes (35) Prospective 31.5 ± 6.9 m 31/35 return to any Return to work: 3 m Return to preinjury 14
20202 35 participated sports (0.5e7) level
in sports 26/35 return to Return to sports
preinjury sports
Vila Rico J 22 29.4, 16/6 Yes Retrospective 34 m 12/12 return to pre- Return to sports: Return to preinjury 12
201927 12 (high level injury levels 21.5 ± 3.0 weeks levels
athletes)
Sun Y 32 31.9, 18/14 NS Retrospective 28 (24e35) 30/32 return to any NS Return to sports 12
201924 m sports
Lopes 171 35.2, 111/60 Yes Prospective 9.6 months Recreational NS Return to preinjury 14
201815 Recreational-67, athletes: 80% return level
Competitive-55, to preinjury level
Professional-7 Competitive: 48%
return to pre injury
levels
Professional 71%
return to pre injury
sports
Li Q 201814 26 Allograft: NS Retrospective Autograft: 26/26 return to any NS Return to sports 19
34.1, 13/3 55.9 m sports
Allograft-16, Autograft: Allograft:
Autograft-10 31.3, 8/2 37.7 m
Dierckman 31 (33 ankles), 28.3, 16/15 Yes Retrospective 38.6 (24 18/31 return to pre NS Return to sports 10
20155 e107) m injury level (based on tegner
27/31 played 22/31 return to any activity level)
competitive or sports
recreational sports
Kim 201511 29 (31 ankles) 24*, 24/52 NS Case-series, 21 (12e51) 25/29 return to NS Return to preinjury 10
Level IV m preinjury level of level
sports
Jung GH 64 (66 ankles) 30.3, 51/19 NS Retrospective 22.1 m (12 NS 3.1 m (6 wks-12 m) Return to sports 9
201510 e68)
Miyamoto 33 Group I: Yes Prospective 24 m 33/33 return to Group I: 18.5 ± 3.5 Return to preinjury 22
201416 27.7, 10/5 preinjury level weeks (range, 10e23 level
Group I: 15, Group A: weeks)
Group A: 18 26.4, 13/5 Group A:
13.4 ± 2.2 weeks (range,
10e18 weeks)
Hua 20128 35 (36 ankle) NS, NS/NS Yes Case series 37.9 (24 33/35 return to NS Return to preinjury 12
e54) m preinjury sports sports
Ibrahim 14 NS, 12/2 Yes case series, 33.5 (32 14/14 return to Return to normal Return to sports 12
20119 LEVEL 4 e48) m sports activities: 12 weeks
(range 7e20 weeks)
Return to sports: 6.8
months (range
4e11 months).
Ellis 20116 11 (12 ankle) 48.9, 4/7 Yes (4 athletes) Retrospective 3.5 years 7/11 return to NS Return to sports 14
preinjury sports
Takao M 21 ATFL tear Yes Prospective 2 years 21/21 return to NS Return to preinjury 14
200525 alone: 30.8, case series previous injury level level
11/6
ATFL þ CFL-
24.5, 3/1
Coughlin 28 (29 ankles) 31, 11/17 Yes (19 athletes) Retrospective 23 (12e52) 28/28 return to any Return to daily Return to sports 9
20043 m sports activities: 12 weeks
(range, 5e24 weeks)
19/19 return to Return to sports: 6.5 Return to preinjury
preinjury levels months (range, 3e12 level
months)
Solakoglu 14 25, 14/0 Yes (Amateur Retrospective 20 (14e32) 14/14 return to 6m Return to preinjury 13
200322 athletes and m preinjury levels level
military personnel)
Paterson 26 24, 12/14 Yes Retrospective 24 (13e46) 26/26 return to any Return to work: 7 Return to sports 12
200019 m sports weeks
(continued on next page)

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B.S. Raja, A.K.S. Gowda, S.K. Bhagat et al.
Table-1 (continued )
Author Sample size, M/ Age, M/F Athletes Study design Follow up
(year) F score21
Okuda 27 (28 ankles) 23, 10/16 Yes (11competitive CASE SERIES, 37 (24e57)
199918 Group A: ATFL and 3 recreational LEVEL 4
injury 11 athletes)
Group B:
ATFL þ CFL - 16
Footnote: ALS-RSI: ankle ligament reconstruction-return to sport after injury; NS- not specified; M/F: male/female; RTS: Return To Sports; ATFL: anterior talofibular ligament;
CFL: calcaneofibular ligament; wk-weeks; m-months; MINORS: methodological index of randomized studies.
agreement was made by the senior author (P.K.M.).
Data obtained from the review was entered in a Microsoft excel
sheet and Open Meta-analyst software was used for proportion
meta-analysis. The primary outcome of the study was the return to
any sports (regardless of sports participation and studies failing to
mention activity level preoperatively) and return to pre-injury
sports (military personnel or athletes). The secondary outcomes
included AOFAS score, VAS score, anterior drawer test (ADT), Talar
Tilt (TT), and Karlsson scores. The return to sports data was used to
obtain the pooled rates of return by proportion meta-analysis using
the random-effects model. Subgroup analysis was done wherever
possible when the I2 statistic was found to be high. Arthroscopic or
open subgroups and subgroups based on the follow-up period were
planned for the study.
2.4. Quality assessment
The authors A.K.S.G. and S.K.B. assessed the quality of the study
using the MINORs score.12 It consists of 12 questionnaires which
have scores 0,1 and 2 for each question, for which the ideal score
being 16 for non-comparative studies and 24 for comparative
studies. In case of any disagreements, the senior author (P.K.M.)
took the final decision.
3. Results
3.1. Search results
The initial search yielded 2356 studies in total, out of which after
the removal of 480 duplicates 1876 studies remained. A final list of
20 articles were included in the qualitative synthesis. Nineteen
studies were included after assessing with inclusion and exclusion
criteria for quantitative synthesis. The search results are depicted in
the flow diagram (Figure-1).
3.2. Study characteristics
Nineteen studies talked about the RTS rates whereas eight
studies mentioned the RTS timeline.13e20 Overall, 733 ankles (720
patients) were included meeting our inclusion criteria. Six articles
used arthroscopic approach for treatment1,5,13,20e22 and thirteen
used open approach.2e4,14,15,17e19,23e27 Eight articles used gracilis
graft, five used semitendinosus graft, three used peroneus graft,
and six used allografts (Table-2). Six studies reconstructed the ATFL
alone4,17,18,21,22,27 whereas fifteen reconstructed both ATFL and
CFL.1e5,13e16,19,20,23e26 The average age of the patients were 30.45
years, there were 426 males and 294 females and the mean follow-
up was 29.7 months with a range of 9.6 monthse55.9 months
(Table-1). 7 studies had follow-up less than 2 years, whereas 13
studies had at least 2 years or more follow up. The study charac-
teristics have been detailed in Tables 1 and 2
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Journal of Clinical Orthopaedics and Trauma 43 (2023) 102227
RTS data RTS timeline RTS parameter MINORS
23/26 return to Return to sports: 12 Return to preinjury
preinjury levels weeks level
14/14 return to NS Return to preinjury 12
m preinjury levels level
3.3. Return to sports
The pooled data analysis revealed return to any sports rates of
95.3% (95%CI: [0.928, 0.977]; I2 ¼ 39.9%; p ¼ 0.046; Fig<2A). The
subgroup analysis revealed a RTS to any sports rates of 92.8% (95%
CI: [0.885, 0.972]; I2 ¼ 0%; p ¼ 0.473; Fig<2B) for arthroscopic and
95.9% (95%CI: [0.931, 0.988]; I2 ¼ 45.52%; p ¼ 0.043; Fig<2C) for
open groups respectively.
The pooled data analysis of RTS for preinjury sports revealed a
rate of 84.3% (95%CI: [0.772, 0.915]; I2 ¼ 89.6%; p < 0.001; Fig<3A).
The subgroup analysis of arthroscopic and open groups revealed
73.1% (95%CI: [0.560, 0.901]; I2 ¼ 92.68%; p < 0.001; Fig<3B) and
93.9% (95%CI: [0.893, 0.985]; I2 ¼ 64.52%; p ¼ 0.003; Fig<3C)
respectively.
3.4. Secondary outcomes
AOFAS was used as an outcome in 13
studies,1,2,4,5,13e16,20e22,24,26 VAS score in 8 studies2,3,13,15,16,19,22,23
and Karlsson score in 13 studies.1e3,5,13e17,21,24e26 The pooled
analysis revealed a statistically significant improvement in the
AOFAS, VAS and Karlsson scores postoperatively. The pooled AOFAS
scores was 94.1% (95%CI: [0.924, 0.959]; I2 ¼ 50.43%; p ¼ 0.019;
Fig<4), VAS scores was 15.5% (95%CI: [0.066, 0.244]; I2 ¼ 30.89%;
p ¼ 0.181; Fig<5) and Karlsson score was 91.7% (95%CI: [0.898,
0.937]; I2 ¼ 45.19%; p ¼ 0.039; Fig<6) respectively.
4. Discussion
The most important finding in this study was that the return to
preinjury level in the athletes was 84.3% following reconstruction
of lateral ankle ligaments in CLAI. Return to any sports rate was
95.3%. This suggests that there is an increase in the need to opti-
mize the patients for surgery, need for proper counseling of the
patients concerning the expectations and returns after undergoing
the surgery. Our study revealed return to any sports rate of 95%
with rates of 92.8% for arthroscopy and 95.9% for open groups. The
return to recreational activity or any sports are high but, return
rates for pre-injury sports or competitive sports demonstrate
moderate to high rates of return.
The current review aimed to evaluate the use of reconstruction
using grafts in CLAI with help of return to spots rate. To the best of
our knowledge, the current review is the only one in the literature
to comprehensively assess the rates of return to sports in CLAI
treated with reconstruction using grafts. Two systematic reviews
comment on the return to sports rates in literature in ankle in-
juries.7,9 D'Hooghe et al. reviewed multiple procedures including
nonanatomic repair, anatomic repair, and reconstruction together
as a single group, even including studies commenting on acute
lateral ankle injuries and reported an average timeline of 4.7
months for RTS.7 Li et al. in their review used 3 studies with more
than >2 years of duration to comment on the RTS and reported a
4
B.S. Raja, A.K.S. Gowda, S.K. Bhagat et al. Journal of Clinical Orthopaedics and Trauma 43 (2023) 102227

Table-2

Author Graft utilized (autograft or allograft) if Outcomes (AOFAS, VAS, or Anterior drawer test Talar Tilt angle (TT)
(year) autograft which one other scores) (ADT)

Allegra Gracilis AUTOGRAFT AOFAS Preop: 11 MM Preop:11

20201 Preop:37 (range 21e51) Postop: 2.3 MM Postop:6
Postop:94 (from 87 to 100)
Kitaoka Score
Preop:36.7 (range 18e59)
Postop:92.9 (range 90e99)
Sigonney NS (Anatomic reconstruction with AOFAS NS NS
202020 tendon grafts) Preop:81.7 (29.0; 00.0)
Postop: 88.0 (74.0e94.0)
Karlsson
Preop:85.2 (25.0; 100.0)
Postop: 91.1 (80.1e96.7)
Lan S Gracilis autograft AOFAS Preop:13.2 ± 1.5 Preop:15.2 ± 1.5
202012 Preop:56.8 ± 10.5 Postop:4.8 ± 1.1 Postop:4.3 ± 1.2
Postop:90.2 ± 6.2
VAS
Preop:5.7 ± 1.3
Postop:0.5 ± 0.8
Cordier Gracilis Autograft AOFAS Preop:NS Preop:NS
20202 Preop:76.4 ± 15 Postop:NS Postop:NS
Postop:94.7 ± 11.7
Karlsson
Preop:73.0 ± 16.0
Postop:93.7 ± 10.6
VAS
Preop:1.9 ± 2.5
Postop:0.8 ± 1.7
Vila RJ Gracilis allograft AOFAS pre 62.3þ-6.7 postop NS NS
201927 97.2þ-3.2
Sun Y Peroneus longus tendon (anterior AOFAS Preop:13.8 ± 3.4 Preop:14.1 ± 4.2
201924 half) autograft Preop:59.6 ± 6.0 Post Op:3.6 ± 1.5 Post Op:3.4 ± 1.3
Post Op:92.8 ± 4.9
Karlsson
Preop:55.7 ± 7.9
Post Op:92.1 ± 7.7
Lopes Gracillis autograft AOFAS NS NS
201815 Preop:62.1 ± 19.2
Postop:89.2 ± 13.3
Karlsson
Preop:55 ± 17.2
Postop:87.1 ± 14.9
Li Q 201814 Allograft: Semitendinosus Allograft group NS NS
Autograft: Semitendinosus AOFAS
Preop:69.9 ± 13.3
Post Op:94.8 ± 5.4
Karlsson
Preop:70.3 ±
12.2
Post Op:93.8 ± 5.6
Autograft group
AOFAS
Preop:68.4 ± 10.0
Post Op:94.7 ± 5.0
Karlsson
Preop:64.5 ± 14.4
Post Op:95.0 ± 5.8
Kim 201511 Peroneus longus tendon (anterior Karlsson score Preop:7.3 ± 2.6 Preop:15.7 ± 3.5
half) Preop:58.2 ± 10.9 Post Op:4.1 ± 1.7 Post Op:4.6 ± 1.7
Post Op:83.9 ± 7.0
Dierckman Semitendinosus allograft VAS Preop:NS Preop:14.3 ± 5.4
20155 Preop:7.3 ± 1.3 Postop:1.8 ± 1.1 Postop:3.1 ± 2.4
Postop:1.9 ± 1.8
Tegner activity
Preop:6.9 ± 2.8
Postop:6.0 ± 2.4
Jung GH Semitendinosus allograft AOFAS NS: Preop:14.7
201510 Preop:71.0 Post Op:3.8
Post Op:90.9
Karlsson
Preop:54.8
Post Op:89.8
VAS
Preop:5.6
(continued on next page)

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Table-2 (continued )

Author Graft utilized (autograft or allograft) if Outcomes (AOFAS, VAS, or Anterior drawer test Talar Tilt angle (TT)
(year) autograft which one other scores) (ADT)

Post Op:1.4
Miyamoto Gracilis autograft Group I Group I Group I
201416 Karlsson score Preop:7.7 ± 1.8 Preop:8.7 ± 2.6
Preop:62.3 6 ± 4.7 Post Op:4.0 ± 1.6 Postop:3.8 ± 1.5
Post Op:94.4 ± 7.1 Group A Group A
Group A Preop:8.7 ± 2.1 Preop:10.5 ± 3.4
Karlsson score Post op:4.3 ± 1.2 Postop:4.3 ± 1.8
Preop:64.1 ± 4.8
Post Op:91.7 ± 7.7
Hua 20128 Semitendinosus allograft AOFAS NS NS
Preop:42.3 ± 4.9
Postop: 90.4 ± 6.7
Karlsson score
Preop:38.5 ± 3.2
Post Op:90.1 ± 7.8
Ellis 20116 Anterior tibial tendon allograft VAS Preop: NA Preop: 20.2
Preop: NS postop:6.5 mm Postop: 4.6
Postop:1.8 (range, 0 to 5)
Karlsson:
Preop:NS
Postop:82.3 ± 19.9
Ibrahim Gracilis autograft AOFAS pre op:58 (30e70) preop:11 mm (range pre op:12 (range 3e25)
20119 post op:96 (80e100) 4e15 mm) postop: 3 (range 1e25)
VAS preop: 6.8 (3e10) postop:4 mm (range
post op:6 (0e4) 1e8 mm)
Karlsson pre op:NA
post op:94.7 (80e100)
Takao M GRACILIS autograft AOFAS NA Only ATFL reconstruction (17 patient):
200525 PREOP: 69.4 ± 4.0 (range, 64 PREOP 14.5 ± 1.7
e77) POST OP 2.6 ± 0.8
POSTOP: 97.0 ± 2.6 (range, 90 4 patients who had both the anterior talofibular ligament and
e100) calcaneofibular ligament reconstructed,
PREOP: 16.5 ± 1.5
POST OP 3.0 ± 0.5
Coughlin Gracilis AUTOGRAFT AOFAS Preop:10 mm Preop:13 (range, 3 30 )
20043 Preop:57 (32e74) (range, 4e17 mm) Postop:3 (range, 1 9 )
Post Op:98 (87e100) Postop:5 mm (range,
VAS 1e9 mm
Preop: 7.2 (3e10)
Postop: 0.6 (0e4) Karlsson
Preop: NA
Postop:95.3 (82e100)
Solakoglu SPLIT PERONEUS BREVIS TENDON NA PREOP:11.8 (range PREOP:16.1 (range 12e20 )
200322 AUTOGRAFT 12e14) mm
POSTOP: 1.6 (range POSTOP: 1.6 (range 0e3 )
1e3)
Paterson Semitendinosus AUTOGRAFT NA Operated ankle:6.4 Operated ankle: 5.4 (±2.4)
200019 (±2.2)
Contralateral Contralateral ankle: 5.3 (±2.4)
ankle:6.5 (±2.2)
Okuda Palmaris tendon autograft NS Group A Group A
199918 In plantar flexion Preop:17.8 ± 3.4 (9.4e22.2)
Preop:12.7 ± 1.8 (10 Post Op:9.8 ± 4.2 (3.2e15.4)
e16) Group B
Post Op:5.0 ± 2.5 (1 Preop:22.9 ± 4.7 (15.6e32.4)
e10) Post Op:11.3 ± 4.4 (3.1e20.7)
In dorsiflexion
Preop:6.6 ± 2.9 (0
e12)
Post Op:3.2 ± 2.4 (0
e8)
Group B
In plantar flexion
Preop:17.5 ± 3.4 (12
e23)
Post Op:5.5 ± 2.8 (2
e13)
In dorsiflexion
Preop:13.3 ± 4.3 (6
e21)
Post Op:3.8 ± 3.3 (0
e12)

Footnote: NS: not specified; VAS: Visual Analogue scale; AOFAS: American Orthopedic Foot and Ankle society; Preop-Pre-operative; Postop: Post-operative; NA: not available.

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B.S. Raja, A.K.S. Gowda, S.K. Bhagat et al.
return to sports rate of 80% in 77 patients undergoing reconstruc-
tion. This study also revealed RTS for preinjury sports revealed a
rate of 84.3% with 73.1% for arthroscopic and 93.9% for open groups.
The current study found that the average time taken by the
participants in various studies included in this review took 17weeks
to return to preinjury level of sports. The largest of the series was by
Lopes et al. who evaluated 171 patients undergoing arthroscopic
reconstruction and noted 80% and 48% rates of return to recrea-
tional and professional sports respectively.5 Of the included studies,
9 studies commented on the time to return to professional ath-
letes.5,20,27 The cause for decreased return to sports activity is likely
multifactorial and very difficult to quantify, yet one may attribute it
to the indication of the surgery wherein most individuals have
attenuated tissue remnants or associated lesions.7,8,10 The experi-
ence of the surgeon, the approach is taken and the variability in
fixation methods may also contribute to patients' outcome and
return to play. Many studies point to the increased patient
perception or fear of injury as a prominent cause of decreased re-
turn to sports.1,13 Some patients had a recurrence of instability
which decreased the return.23 Many had neuralgia of superficial
peroneal nerve or pain or stiffness in their joints but none of these
were limiting factors in the majority of the studies.13,23 Ankle
reconstruction stems from the idea that the use of free tendon
grafts is independent of the local tissue condition. In our study 6
authors used grafts to reconstruct ATFL only4,17,18,21,22,27 and 15
authors both ATFL and CFL in those cases with both ligament
damage.1e5,13e16,19,20,23e26 But, it was noted that the majority of the
articles did ATFL and CFL reconstruction in cases of suspected or
confirmed ATFL and CFL tears.13,26,27 Allegra and Miyamoto recon-
structed ATFL in cases with isolated ATFL injury.17,21 Takao et al.
reconstructed CFL in those cases where there was subtalar joint
instability suspecting CFL tear.4 Paterson reconstructed ATFL alone
and noted instability in 5 cases out of 26 cases. He suspected CFL
tears in these cases.18 However, Okuda argued that combined ATFL
and CFL reconstruction is not necessary for combined ligament
injuries.27 A recent systematic review by Song Y et al. based on
available evidence advised to repair or reconstruct both ATFL and
CFL in case of injuries to both.6 The subgroup analysis revealed
open reconstruction procedures having better rates of return
compared to the arthroscopic techniques. More comparative
studies are needed to comment on the above finding.
The functional outcomes of patients undergoing reconstruction
showed significant postoperative improvement. The recurrence of
instability was low as evidenced by the decreased talar tilt and
anterior drawer test excursion postoperatively.2,21,22 The pain
scores which often point out to the patients’ perception was also
significantly decreased post-surgery which indicated that pain was
often not the cause of decreased return to injury. Overall, the
functional assessment in our review was similar to the existing
literature.9 The ankle movements were also seen to be not
restricted in the studies.4,15 The review found that most of the
patients returned to sports on an average of 17 (range; 12e27.2)
weeks.24 The criteria or metric for determining the return to sports
were not specified in many articles. Song et al. noted multiple
metrics such as Joint stability, muscle strength and ROM can be
used as metrics to assess the return to sports.6 A systematic review
by Glazebrook et al. noted faster rates of recovery following
accelerated rehabilitation compared to delayed rehabilitation.8 But
ultimately the return to actual sports depends upon patients'
capabilities.
Although arthroscopy has the advantages of smaller incision,
lesser scarring, less chances of infection and overall better reha-
bilitation compared to open procedure, but it was not the case in
our study. The reason may be due to the fact that ankle arthroscopic
reconstruction is a new frontier and there may be constraints in the
7
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Journal of Clinical Orthopaedics and Trauma 43 (2023) 102227
techniques and implant quality compared to those used in age-old
open techniques. Moreover, ankle arthroscopic procedures require
substantial experience our a period of time to get good results.
Better results can be expected once the techniques and their
biomechanical correlations are done.
The present study offers rates of return in the field of lateral
ankle reconstruction using grafts in CLAI. One can use the RTS rates
to adequately counsel the patients and to answer questions on the
rates of return. However, our study has potential limitations. First,
the included studies were majority level III or IV studies, as such
there may be selection bias. Second, many of the studies had a
follow up period of less than 2 years. Ideally one would need a
larger follow up to understand the actual long-term effects. Third,
there was heterogeneity in the techniques, grafts used and data
reporting in the studies which may have created bias. Fourth,
although we had done a thorough search of literature, we may have
left out studies which were not evident. However, even with all the
above limitations the current study is the best available literature
that would be available for the surgeons for counseling patients
regarding the reconstruction with grafts in CLAI.
5. Conclusion
The RTS rates following reconstruction using grafts in CLAI was
found to be 95.3% for return to any sports, 84.3% for return to
preinjury sports. The average time taken for return to sports was 17
weeks. Newer studies on identifying the potential risk factors
associated with return to sports and the optimal rehabilitation
protocols are the need of the day.
Ethics approval
Approval from the institutional ethics committee was not
required for this review article.
Consent to participate
No participants were enrolled for this review article. Hence,
informed consent was not required.
Consent to Publish
All authors have read the final prepared draft of the manuscript
and approve this version, in its current format if considered further
for publication.
Authors contribution
First Author - Planning of study, literature search, writing the
manuscript, quality assessment of the included studies. Second
Author- Data management, outcome assessment, manuscript
preparation. Third Authore Data management, outcome assess-
ment, quality assessment of the included studies, Fourth Author-
Literature search, quality assessment of the included studies. Cor-
responding Author- Planning of study, quality assessment of the
included studies, writing and revising the manuscript.
Financial support and sponsorship
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Availability of data and materials materials-methods
All included studies used in this systematic review and meta-
B.S. Raja, A.K.S. Gowda, S.K. Bhagat et al. Journal of Clinical Orthopaedics and Trauma 43 (2023) 102227

analysis are available online. The datasets used and/or analysed
during the current study are available from the corresponding
author on reasonable request. Data regarding this study is not
available in any electronic databases.
Declaration of competing interest
The authors declare that they have no known competing
financial interests or personal relationships that could have
appeared to influence the work reported in this paper.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jcot.2023.102227.
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exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.