Foot and Ankle International - 2026-03-28 - Journal Article
Impact of Calcaneofibular Ligament Morphology on Recurrent Instability Following Arthroscopic Anterior Lateral Ankle Ligament Repair for Chronic Ankle Instability.
Nakasa T, Ikuta Y, Sakurai S, Ishibashi S, Moriwaki D, Chujo T, Adachi N
Topics
Key Takeaway
CFL injury on preoperative MRI independently predicts recurrent instability after arthroscopic ATFL repair with an OR of 9.00 (95% CI 1.95–56.22), with thin-type CFL morphology carrying a 31.5% recurrence rate.
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Summary
This retrospective cohort investigated whether preoperative MRI-classified CFL morphology (intact, wavy, thin) predicts recurrent instability after arthroscopic ATFL repair in 65 ankles. CFL injury was present in 58.5% of ankles; recurrence occurred in 20% overall, with thin-type CFL carrying 31.5% and wavy-type 26.3% recurrence rates. Multivariable Firth logistic regression identified CFL injury as an independent predictor of recurrence (OR 9.00), while additional CFL repair showed a protective but non-significant trend.
Key Limitation
The non-standardized decision to perform concomitant CFL repair confounds the ability to quantify the protective effect of CFL repair, which is the most actionable clinical question this study raises.
Original Abstract
BACKGROUND
Arthroscopic anterior talofibular ligament (ATFL) repair for chronic lateral ankle instability (CLAI) has shown favorable outcomes; however, instability recurrence has been reported. CLAI is frequently associated with concomitant calcaneofibular ligament (CFL) injury; its effects on postoperative outcomes remain unclear. This study aimed to investigate the association between preoperative magnetic resonance imaging (MRI) findings of the CFL and postoperative recurrence.
METHODS
This hypothesis-testing retrospective cohort study included 65 ankles in 60 patients (mean age, 34.0 ± 16.0 years) who underwent arthroscopic ATFL repair between November 2019 and June 2024. Preoperative oblique coronal MRI was used to classify the CFL morphology as intact, wavy, or thin. Clinical outcomes were assessed using the Japanese Society for Surgery of the Foot (JSSF) hindfoot-ankle scale, Karlsson- Peterson (K-P) score, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q). Recurrent ankle instability, defined as any postoperative ankle sprain during follow-up, was recorded. Multivariable analysis was performed to identify independent recurrent instability predictors.
RESULTS
Postoperative JSSF, K-P, and SAFE-Q scores improved significantly in all patients. Recurrent instability occurred in 13 of the 65 ankles (20.0%). Preoperative MRI revealed CFL injury in 38 ankles (58.5%). Additional CFL repair was performed in 24 ankles. Recurrence rates were higher in ankles with CFL injuries, particularly in those with thin (31.5%) and wavy (26.3%) morphologies. In the Firth model, CFL injury was independently associated with recurrence (OR 9.00, 95% CI 1.95-56.22, P = .004), whereas CFL repair showed a protective trend. Bootstrap analysis confirmed the significance of CFL injury.
CONCLUSION
Preoperative MRI evaluation of CFL morphology is a significant predictor for identifying risk of postoperative recurrence after arthroscopic ATFL repair. CFL injury, particularly thin-type morphology, is associated with higher recurrence rates, suggesting the need for additional reconstructive or augmentative procedures to optimize clinical outcomes.