OBJECTIVES Anterior talofibular ligament (ATFL) injury is one of the most common injuries in sports medicine, resulting in chronic lateral ankle instability (CLAI). The patients' daily life may be seriously affected by ankle osteoarthritis and other irreversible damages, if the ATFL injury is not treated in time and drags on. Patients with ATFL injury who show no significant recovery after 3-6 months of conservative treatment should consider surgical treatment as soon as possible to restore ankle stability and function. This study aims to investigate the effect of double-bands anatomical reconstruction of the ATFL's fibular enthesis for the treatment of CLAI. METHODS A retrospective review was conducted on 67 patients diagnosed with CLAI in the Department of Sports Medicine, Xiangya Hospital, Central South University from January 2015 to January 2018, including 42 males and 25 females, aged from 17 to 41 years old, with disease course of (12.6±3.2) months. Of the 67 patients, 29 left ankles and 38 right ankles were included in this study. Patients suffered from repeated sprains which leaded to pain, swelling and obvious ankle relaxation. There were obvious tenderness at the ATFL insertion and the calcaneal fibular ligament insertion. Both the anterior ankle drawer test and the varus stress test were positive. Other ankle disorders were excluded by X-ray. Preoperative color Doppler ultrasonography and magnetic resonance examination were performed to observe ATFL injury. All the patients had surgical indications and no obvious contraindications, and they were treated with arthroscopic debridement and double-bundle anatomical reconstruction of the AFTL's fibular enthesis under anesthesia. Postoperative routine nursing and standardized rehabilitation exercise were recommended. Outpatient follow-up was conducted at 3, 6, 12, and 24 months postoperatively. American Orthopaedic Foot and Ankle Society (AOFAS) scores, Karlsson Ankle Functional (KAF) score, and the Japanese Society for Surgery of the Foot (JSSF) scale were used to evaluate the clinical outcomes. RESULTS Intraoperative arthroscopic examination of 67 patients showed inflammatory synovial hyperplasia in 52 cases (77.6%), obvious osteophyte hyperplasia in 12 cases (17.9%), talus osteochondral injury of grade II-III in 23 cases (34.3%), and cartilage injury of grade IV in 5 cases (7.5%). All operations were carried out successfully, and both the anterior ankle drawer test and the varus stress test were negative under anesthesia after surgery. The anchors were in good position. Among them, 3 patients (4.5%) got temporary superficial peroneal nerve palsy and skin numbness at ankle joint after surgery, which gradually recovered within 2 weeks. There were no serious perioperative complications such as infection and suppurative arthritis. Postoperative follow-up was conducted for 12-24 (15.64±3.17) months. At the last follow-up, all patients were walking normally. Most patients had no pain or occasionally mild pain. Ankle function and motion were restored without re-instability. Sixty-four patients (95.5%) worked and exercised as before the surgery. Standing X-ray examination indicated normal joint space without stenosis, and the internal fixation was in good position. Postoperative AOFAS scores (94.78±6.37) were significantly better than the preoperative scores (64.17±12.43, P<0.01). Besides, the KAF scores and the JSSF ankle/hindfoot scale before surgery were significantly increased (KAF: 91.04±11.36 vs 59.74±13.63, P<0.01; JSSF: 95.32±10.21 vs 66.92±14.38, P<0.01). CONCLUSIONS Arthroscopic debridement and double-bands anatomical reconstruction of the ATFL's fibular enthesis for the treatment of CLAI gains beneficial short-term effects for its minimal invasion and quick recovery. 目的: 距腓前韧带(anterior talofibular ligament，ATFL)损伤是运动医学领域最常见的损伤性疾病之一，常导致踝关节外侧不稳定，如未获得及时有效的治疗，病情长期迁延反复，将发展为踝骨关节炎而出现不可逆性损害，严重影响患者的日常生活。经保守治疗3~6个月后未见明显好转的ATFL损伤患者应尽早考虑手术修复以恢复踝关节的稳定性和功能。本研究旨在探讨ATFL腓骨止点双束解剖重建治疗慢性踝关节外侧不稳的临床疗效。方法: 回顾性调查2015年1月至2018年1月间在中南大学湘雅医院运动医学科诊断为慢性踝关节外侧不稳的67例患者，其中男42例，女25例，年龄17~41岁，病程为(12.6±3.2)个月；左踝29例，右踝38例。患者均因反复扭伤导致踝关节疼痛、肿胀、关节明显松弛；ATFL止点压痛、跟腓韧带止点压痛、踝关节前抽屉试验、内翻应力试验均为阳性。采用X线检查排除其他踝关节疾患，术前采用彩色多普勒超声和磁共振检查观察患侧ATFL损伤情况。患者均有手术指征且无明显手术禁忌证，在神经阻滞麻醉下采用踝关节镜下清理并ATFL腓骨止点双束解剖重建手术治疗。术后予以常规护理及标准化流程的康复锻炼。术后3、6、12、24个月进行门诊随访，使用美国足踝外科协会(American Orthopaedic Foot and Ankle Society，AOFAS)评分、卡尔森踝关节功能(Karlsson ankle functional，KAF)评分及日本足踝外科学会(the Japanese Society for Surgery of the Foot，JSSF)量表评分评价临床结果。结果: 67例患者在术中关节镜下检查发现炎性滑膜增生52例(77.6%)，明显骨赘增生12例(17.9%)，II~III度距骨骨软骨损伤23例(34.3%)，IV度软骨损伤5例(7.5%)。所有患者顺利完成手术，术后在麻醉状态下前抽屉试验为阴性、内翻应力试验为阴性；术后锚钉位置良好。其中3例(4.5%)患者术后出现腓浅神经暂时性麻痹，足踝部皮肤麻木，2周内逐渐恢复；无围手术期感染、化脓性关节炎等严重围手术期并发症。术后随访12~24(15.64±3.17)个月。末次随访时，所有患者可以正常行走；踝关节疼痛较术前明显好转，大多数患者无疼痛或偶有轻度疼痛；踝关节的功能及活动度得到恢复，没有发生再次失稳。64例(95.5%)患者可以恢复至伤前的劳动或运动水平。站立位X线检查提示关节间隙良好，未见狭窄；内固定位置良好。术后AOFAS评分(94.78±6.37)明显优于术前(64.17±12.43，P<0.01)，KAF评分和JSSF量表评分较术前均显著增加，差异具有统计学意义(KAF：91.04±11.36 vs 59.74±13.63，P<0.01；JSSF：95.32±10.21 vs 66.92±14.38，P<0.01)。结论: 关节镜下清理并ATFL腓骨止点双束解剖重建治疗慢性踝关节外侧不稳具有创伤小、恢复快的优点，近期疗效良好。.

中文翻译：

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距腓前韧带腓骨附着点双束带解剖重建治疗慢性踝关节外侧不稳。

目的 距腓前韧带 (ATFL) 损伤是运动医学中最常见的损伤之一，可导致慢性外侧踝关节不稳定 (CLAI)。如果ATFL损伤不及时治疗并持续下去，患者的日常生活可能会受到踝关节骨性关节炎和其他不可逆损伤的严重影响。ATFL损伤患者保守治疗3-6个月后无明显恢复，应尽快考虑手术治疗，以恢复踝关节稳定性和功能。本研究旨在探讨ATFL腓骨附着点双波段解剖重建治疗CLAI的效果。方法对湘雅医院运动医学科67例CLAI患者进行回顾性分析。中南大学2015年1月至2018年1月，其中男42例，女25例，年龄17～41岁，病程（12.6±3.2）个月。67 名患者中，29 名左脚踝和 38 名右脚踝被纳入本研究。患者反复扭伤，导致疼痛、肿胀和明显的踝关节松弛。ATFL插入处和跟腓韧带插入处有明显压痛。前踝抽屉试验和内翻应力试验均为阳性。X 线检查排除了其他踝关节疾病。术前行彩色多普勒超声及磁共振检查，观察ATFL损伤情况。所有患者均有手术指征，无明显禁忌症，他们在麻醉下接受了关节镜下清创和AFTL腓骨附着点双束解剖重建。推荐术后常规护理和标准化康复锻炼。术后3、6、12、24个月进行门诊随访。采用美国足踝骨科协会 (AOFAS) 评分、卡尔森踝关节功能 (KAF) 评分和日本足部外科协会 (JSSF) 量表评估临床结果。结果 67例患者术中关节镜检查示炎性滑膜增生52例（77.6%），明显骨赘增生12例（17.9%），距骨骨软骨Ⅱ-Ⅲ级损伤23例（34.3%），软骨损伤23例（34.3%）。 Ⅳ级5例（7.5%）。所有手术均顺利进行，术后麻醉下踝前牵引试验和内翻应力试验均为阴性。锚的位置很好。其中3例（4.5%）患者术后出现暂时性腓浅神经麻痹及踝关节皮肤麻木，2周内逐渐恢复。无感染、化脓性关节炎等严重围手术期并发症。术后随访12～24（15.64±3.17）个月。末次随访时，所有患者行走正常。大多数患者没有疼痛或偶尔有轻微疼痛。踝关节功能和运动恢复，没有再次不稳定。64 名患者 (95.5%) 与手术前一样工作和锻炼。站立 X 线检查表明关节间隙正常，无狭窄，内固定位置良好。术后AOFAS评分（94.78±6.37）明显优于术前评分（64.17±12.43，P<0.01）。此外，术前KAF评分和JSSF踝/后足量表显着增加（KAF：91.04±11.36 vs 59.74±13.63，P<0.01；JSSF：95.32±10.21 vs 66.92±14.38，P<0.01）。结论 关节镜下清创联合双带解剖重建ATFL腓骨附着点治疗CLAI具有创伤小、恢复快的近期疗效。腓肠肌运动的最有效部位是关节运动的部位（最常见的部位），导致经常关节疼痛，如未及时获得有效的治疗，长期迁入反复发作，经 3 个月后未明显明显好转的患者接受手术治疗后关节关节的稳定性和功能性改善。用于研究双方法 ATFL 止骨治疗分析治疗方法的临床症状不稳。