908858

research-article2020
FAIXXX10.1177/1071100720908858Foot & Ankle InternationalFeng et al

Article

Foot & Ankle International®

Functional Results of All-Inside

1­–7
© The Author(s) 2020
Article reuse guidelines:
Arthroscopic Broström-Gould Surgery sagepub.com/journals-permissions
DOI: 10.1177/1071100720908858
https://doi.org/10.1177/1071100720908858

With 2 Anchors Versus Single Anchor journals.sagepub.com/home/fai

Shi-Ming Feng, MD1,2 , Ai-Guo Wang, MD1,2,

Qing-Qing Sun, MD1, and Zai-Yi Zhang, MD1

Abstract
Background: The all-inside arthroscopic Broström-Gould technique gained particular attention among clinicians and
researchers due to its high rate of satisfactory results. Thus far, there is a lack of evidence regarding the differences in
clinical outcomes between the use of 1 anchor and 2 anchors. The purpose of this study was to compare the differences
in clinical function and activity levels in patients treated with 1 or 2 anchors in all-inside arthroscopic Broström-Gould
surgery for chronic lateral ankle instability (CLAI).
Methods: The data of 75 patients with CLAI (unilateral) admitted from May 2013 to July 2016 were retrospectively
analyzed. All patients were treated with all-inside arthroscopic Broström-Gould surgery. The patients were divided into a
single-anchor group (n = 36) and double-anchor group (n = 39) according to the number of anchors used. There was no
statistical difference in general characteristics between the 2 groups before surgery. After 36 to 72 months of follow-up,
the pain visual analog scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS) score, Karlsson Ankle
Functional Score (KAFS), and Foot and Ankle Outcome Score (FAOS) were used to evaluate and compare the clinical
function results between the 2 groups.
Results: The incidence of wound complications; reaction to the suture; injury to the nerve, blood vessel, or tendon; and
length of postoperative hospitalization were similar between the 2 groups. At the last follow-up, there was no significant
difference in the VAS and AOFAS scores between single- and double-anchor groups, but the KAFS and FAOS in the
double-anchor group were significantly higher than in the single-anchor group. Additionally, more patients in the double-
anchor group returned to preinjury sports activities.
Conclusion: All-inside arthroscopic Broström-Gould surgery for the treatment of CLAI yielded a better functional effect
and better recovery to preinjury mobility when 2 anchors were used instead of a single anchor.
Level of Evidence: Level III, comparative study.

Keywords: chronic lateral ankle instability, arthroscopic repair, Broström-Gould procedure, anchor fixation

Introduction procedure for the treatment of CLAI. The all-inside

The lateral ankle ligaments include the anterior talofibular
ligament (ATFL), calcaneofibular ligament, and posterior
talofibular ligament. Among them, the ATFL is the one
most frequently damaged with lateral ankle ligament
injury.2,12 Chronic lateral ankle instability (CLAI) resulting
from the lateral ankle ligament injury is a common problem
of the ankle.18 Clinically, the first-line surgical treatment for
CLAI is the open Broström-Gould surgery.13,27 This proce-
dure has the advantage of effective restoration of lateral sta-
bility of the ankle joint without the need for tendon
transplantation. To date, a growing number of surgeons
have performed the all-inside arthroscopic Broström-Gould
arthroscopic Broström-Gould technique gained attention
among clinicians and researchers due to its high rate of
1
Hand and Foot Microsurgery Department, Xuzhou Central Hospital,
Xuzhou Clinical College of Xuzhou Medical University, Xuzhou, Jiangsu,
People’s Republic of China
2
Xuzhou Clinical College of Xuzhou Medical University, Xuzhou, Jiangsu,
People’s Republic of China
Corresponding Author:
Shi-Ming Feng, MD, Hand and Foot Microsurgery Department, Xuzhou
Central Hospital, No. 199, Jiefang South Road, Xuzhou, Jiangsu 221009,
China.
Email: fengshiming_04@163.com
2 Foot & Ankle International 00(0)
satisfactory results.3,11 When performing the all-inside
arthroscopic Broström-Gould procedure, some surgeons
prefer 1 anchor for ligament fixation, and others use 2
anchors. However, the decision of whether 1 or 2 anchors
should be used for ligament fixation is based on the prefer-
ence and personal experience of the surgeon rather than
objective evidence. In this regard, there are few publica-
tions addressing the issue of differences in clinical out-
comes between the use of 1 anchor and 2 anchors.
The purpose of the present study was to evaluate and
compare the clinical results and functional effects of all-
inside arthroscopic Broström-Gould surgery for CLAI
with 1 anchor and 2 anchors at least 3 years after the oper-
ation. It was expected that this analysis would provide
evidence-based recommendations regarding the number
of anchors to be implanted in an arthroscopic Broström-
Gould procedure.
Methods
This cohort study was approved by the institutional review
board of our hospital. Each patient signed an informed con-
sent and the Health Insurance Portability and Accountability
Act consent.
Case Inclusion and Exclusion Criteria
The inclusion criteria were (1) patients with CLAI with
recurrent instability after conservative treatment for a
period of at least 6 months, (2) patients without osteochon-
dral defect or with a defect size no more than 1.5 cm2,9 (3)
patients who were treated with the all-inside arthroscopic
Broström-Gould procedure with 1 or 2 suture anchors
(Fastin RC 3.5 mm; Smith & Nephew, Andover, MA), and
(4) patients with at least 36 months of follow-up. Participants
were excluded if they had any of the following: (1) absent
ATFL or secondary ankle injury after the operation; (2)
complications from a ligament injury or other combined
syndrome; (3) instability of the subtalar joint or systemic
ligament laxity; (4) nerve and muscle atrophy, such as pro-
gressive conditions that cause loss of muscle mass and
weakness, or an injury or condition that damaged the nerves
that control the muscles, resulting in neuromuscular disor-
ders like Charcot-Marie-Tooth disease (these disorders
were proved by clinical examination, electromyography,
and neuromuscular ultrasound20); or (5) obvious abnormali-
ties and deformities of lower limb alignment.
General Information
The surgical indications were as follows: (1) conservative
treatment, including peroneal tendon strengthening and
proprioceptive training for at least 6 months with no relief
of ankle symptoms; (2) a positive contrast ankle anterior
drawer test or stress radiographic ankle varus stress test
showing evidence of instability compared with the unin-
volved side; and (3) preoperative magnetic resonance imag-
ing (MRI) scans showing an ATFL injury.
Enrolled in the study were 184 consecutive patients with
CLAI undergoing all-inside arthroscopic Broström-Gould
surgery from May 2013 to July 2016. All procedures were
performed by the same senior surgeon (S.M.F.) with exten-
sive experience in foot and ankle surgery, who was not
involved in postoperative follow-up. All patients had unilat-
eral CLAI, and there were no obvious abnormalities or
deformities of lower limb alignment, instability of the sub-
talar joint, systemic ligament laxity, nerve and muscle atro-
phy, injury of the posterior talofibular ligament, or fracture
of the ankle. Twenty-seven patients were lost during the
3-year follow-up period, 23 patients were followed up for
less than 36 months, 18 patients underwent osteochondral
transplantation, 15 patients experienced complications from
sinus tarsi syndrome, 14 patients experienced complica-
tions from calcaneofibular ligament injury, 9 patients under-
went medial ankle ligament repair during the surgery, and 3
patients developed secondary injuries to the lateral ankle
ligaments. All of the above cases were excluded from the
analysis, leaving 75 patients included in the study.
The patients were divided into 2 groups according to the
number of suture anchors. Patients were recommended to
have 2-anchor fixation. In patients who refused ligament
fixation with 2 anchors, 1 anchor was used (they paid less if
1 anchor was used). There were 36 cases in the single-anchor
group and 39 cases in the double-anchor group (Figure 1).
The 2 groups were similar in terms of age, body mass index,
concomitant injury, follow-up time, preoperative visual ana-
log scale (VAS) score, American Orthopaedic Foot & Ankle
Society (AOFAS) score, Karlsson Ankle Functional Score
(KAFS), Foot and Ankle Outcome Score (FAOS), and other
general conditions between the 2 groups (Table 1). There
was no significant difference in the preoperative anterior
drawer test grading between the 2 groups (Table 1). The
anterior drawer test was graded according to Maffulli’s cri-
teria in which tibial-talus point-to-point activity within 5
mm in the supine position and in the neutral ankle position is
considered normal, that is, grade 0; 5- to 10-mm point-to-
point activity corresponds to grade 1; 10- to 15-mm point-to-
point activity corresponds to grade 2; and point-to-point
activity greater than 15 mm corresponds to grade 3.19
Therapeutic Method
For all of the patients, standard anterolateral and anterome-
dial portals to the ankle joint were used first to explore and
debride the lesions in the ankle cavity, clear the proliferative
synovial tissue, and remove incarcerated or compressed soft
tissue. Microfracture was performed in patients with a talus
cartilage lesion with an osteochondral defect size less than
Feng et al 3

Figure 1.  Flow diagram of the study.

Table 1.  Characterization of the Sample.

Variable Single-Anchor Group (n = 36) Double-Anchor Group (n = 39) P Valuea

Age, y 32.3 ± 8.4 30.9 ± 10.0 .533c
Sex .460b
 Male 22 27  
 Female 14 12  
BMI, kg/m2 25.1 ± 2.7 24.8 ± 2.2 .551c
Concomitant injuries  
 STS 7 11 .375b
 OCD 11 14 .624b
VAS, mm 54.2 ± 16.8 52.6 ± 15.5 .674c
AOFAS 75.2 ± 10.4 75.0 ± 12.0 .948c
KAFS 69.3 ± 9.7 68.8 ± 10.6 .835c
FAOS 65.7 ± 11.3 67.2 ± 10.8 .569c
Anterior drawer test .451b
  Grade 2 26 25  
  Grade 3 10 14  
Disease duration, mo 15.6 ± 5.3 16.3 ± 4.8 .544c
Follow-up time, mo 44.0 ± 9.2 43.7 ± 8.7 .881c

Abbreviations: AOFAS, American Orthopaedic Foot & Ankle Society; BMI, body mass index; FAOS, Foot and Ankle Outcome Score; KAFS, Karlsson
Ankle Functional Score; OCD, osteochondral defect; STS, sinus tarsi syndrome; VAS, visual analog scale.
a
P < .05 was considered statistically significant.
b
Pearson χ2 test.
c
t test.

1.5 cm2. However, for patients with a larger defect size,
arthroscopic marrow stimulation was not used and osteo-
chondral transplantation was required.9,21 Subsequently, the
anterior approach to the fibular apex was established to
explore the ATFL, clean up the proliferative surrounding tis-
sue, expose the footprint area, and freshen the bone in this
area. The site of anchor insertion in the single-anchor group
was in the midpoint of the footprint area. In the double-
anchor group, the first anchor was fixed at 1.0 cm from the
proximal end of the fibula tip, and the second anchor was
fixed at the proximal end of the fibula in the footprint area.
After all sutures were passed through the ATFL and extensor
retinaculum (Figure 2), a slight valgus position of the ankle
joint (approximately 5 degrees) was established and the
suture knot was tightened with a knot pusher.
Postoperative Management
After the operation, patients were performing functional
exercises under the guidance of a rehabilitation specialist.
4 Foot & Ankle International 00(0)
Figure 2.  Diagram showing the Broström-Gould surgical procedure in the (A) single-anchor group and (B) double-anchor group.
Following the surgery, the ankle joint was fixed in mild dor-
siflexion and valgus position with a short leg brace.
Antibiotics were routinely administered for 24 hours after
the operation. On the second day, patients were instructed to
perform early a weightless floor exercise and an isometric
exercise of the lower limb muscles. Two weeks after the
procedure, the sutures were removed. For patients with
microfracture associated with the treatment of a talar carti-
lage injury, their braces remained fixed for 6 weeks; the rest
of the patients had their braces removed after 4 weeks.
Following the removal of the braces, patients were fitted
with ankle walking boots. The rehabilitation department
assisted the patients with strength exercises for the muscles
around the ankle. After 8 weeks, the patients progressively
increased their training involving activities of the ankle
with varus and plantarflexion. At 12 weeks after the opera-
tion, the patients were allowed to gradually resume normal
physical activity.
Evaluation of Outcomes
All outcomes were evaluated by an experienced ankle sur-
geon who was blinded to the procedure. Postoperative func-
tional scores included the VAS score, AOFAS score, KAFS,
and FAOS. The main clinical evaluations included the stress
radiographic varus stress test and the anterior drawer test.
The stress radiographic varus stress test was performed using
a Telos device with 150 N of force (Weiterstadt, Germany). A
talar tilt angle greater than 10 degrees or greater than 5
degrees compared with the unaffected side was considered a
positive varus stress test. The results of all clinical evalua-
tions were compared with the unaffected side of the patient.
Statistical Analysis
SPSS version 17.0 software (SPSS, Inc, Chicago, IL) was
used for statistical analyses. Quantitative variables were
expressed as mean ± standard deviation. Categorical vari-
ables were expressed as absolute values and relative fre-
quencies. The Student t test (for normal distribution) or
Mann-Whitney test (for asymmetric distribution) was used
to compare quantitative outcomes between groups. The
Pearson chi-square test was used to evaluate the relation-
ship among nominal categorical variables. P < .05 was
considered to be statistically significant.
Results
Debridement of synovial tissue of the ankle joint was per-
formed in all patients, and microfracture of talus in 25
patients (11 in the single-anchor group vs 14 in the double-
anchor group). All surgical incisions healed primarily.
Complications such as wound infection, nerve injury, vas-
cular injury, and tendon injury did not occur. No patients in
either group experienced suture reaction, implant rejection,
or numbness. The length of hospital stay was comparable
between the 2 groups (Table 2).
At the last follow-up, there was no implant rejection or
suture reaction. The stress radiographic ankle varus stress
test was negative, the anterior drawer test of the ankle was
negative (grade 0), and the motion of the ankle was ade-
quate in all subjects. There was no mechanical or symptom-
atic instability of the ankle, and none of the patients required
revision surgery.
At the last follow-up, the VAS and AOFAS scores were
similar between the single- and double-anchor groups.
However, the KAFS and FAOS in the double-anchor group
were significantly higher than those scores in the single-
anchor group (Table 2). In the single-anchor group, 13
patients resumed their preinjury sports activities and 23
patients chose leisure sports activities (nonintense exercise)
due to the fear of secondary injury to the surgery site. In the
double-anchor group, 27 people returned to preinjury sports
Feng et al 5
Table 2.  Comparison of the 2 Groups.
Single-Anchor Double-Anchor
Variable Group (n = 36) Group (n = 39)
Complications 0 0
VAS, mm 7.2 ± 3.8 6.9 ± 3.2
AOFAS 91.1 ± 10.4 92.6 ± 9.2
KAFS 85.7 ± 11.9 91.6 ± 13.3
FAOS 84.2 ± 9.8 90.1 ± 11.1
LHS, day 3.1 ± 1.0 3.1 ± 1.1
Abbreviations: AOFAS, American Orthopaedic Foot & Ankle Society;
FAOS, Foot and Ankle Outcome Score; KAFS, Karlsson Ankle
Functional Score; LHS, length of hospital stay; VAS, visual analog scale.
a
P < .05 was considered statistically significant.
b
t test.
activities and 12 people chose leisure sports activities for
the same reason. The exercise participation rate was signifi-
cantly higher in the double-anchor group (69.2%) than in
the single-anchor group (36.1%) (P = .018).
Discussion
The open Broström-Gould procedure restores ligament and
joint capsule tension by repairing the lateral ligaments,
tightening the joint capsule, and strengthening the inferior
extensor retinaculum. The latter intervention effectively
protects the repaired ligaments and increases lateral stabil-
ity without sacrificing uninjured tendons. The Broström-
Gould procedure is the “standard surgery” for the first
treatment of CLAI.25,28 More than 90% of patients with
CLAI have intra-articular lesions, including, among others,
synovitis, scar adhesions, talus cartilage injuries, osteo-
phytes, loose bodies, and inferior fibular ossicles.7,23,29
These lesions are the result of a combination of injuries and
changes in the mechanical environment of the joint and fre-
quently remain undetected by preoperative MRI. With
improper treatment of intra-articular lesions, the outcome
of CLAI is poor.5 Therefore, all-inside arthroscopic
Broström-Gould surgery has been recommended and
applied by increasing numbers of clinical scientists and sur-
geons since it can not only repair the lateral ligament injury
but also simultaneously treat the intra-articular lesions,
achieving the same fixation strength and functional effect as
open surgery.1,30 However, the optimal number of anchors
to use to suture and fix ligaments has not been established.
There are only a few publications addressing this issue, and
the number of anchors seems to depend on the preferences
of the surgeon and not on evidence-based guidelines.
Among the investigations dealing with the number of
anchors, Cho and coworkers8 prospectively analyzed and
compared the outcomes of 50 CLAI cases treated with the
open Broström-Gould procedure utilizing a single anchor
(25 patients) and 2 anchors (25 patients). After a follow-up
of at least 2 years, both groups had the same clinical func-
tion. Behrens and collaborators4 performed the Broström-
P Valuea Gould surgery on 10 fresh cadaveric specimens. Two
double-loaded, 3.5-mm-diameter corkscrew suture anchors
— (Arthrex, Inc, Naples, FL) were used for suture. To test the
.644b stability of the lateral ankle ligament, a 170-N load was
.507b applied to simulate anterior drawer and talar tilt tests; nearly
.047b normal results were obtained. Lee and colleagues17 per-
.017b formed the all-inside arthroscopic Broström-Gould surgery
.839b
on 11 cadavers, utilizing an absorbable Bio-Suture Tak
anchor for fixation. The values of torque to failure, degrees
to failure, and working construct stiffness were not statisti-
cally different between this biomechanical experiment and
the traditional open Broström-Gould surgery, indicating
that the all-inside protocol results in the same biomechani-
cal stability as the open surgery. Yeo and coworkers31
treated 25 patients with CLAI with all-inside arthroscopic
Broström-Gould surgery and single-anchor fixation. At the
1-year follow-up, the AOFAS score increased from 67.5 to
90.3 and the KAFS increased from 45.0 to 76.2. Comparison
of these results with the outcomes of 23 open Broström-
Gould surgeries revealed that the single-anchor all-inside
arthroscopic Broström-Gould surgery resulted in the same
clinical efficacy, joint function, and joint stability as the tra-
ditional open Broström-Gould surgery. Corte-Real and
Moreira10 examined 28 patients at 24.5 months after opera-
tion and found that although the average AOFAS score after
surgery with 1 fixed anchor was 85.3, 2 patients (7%) expe-
rienced recurrence of the condition. However, the fixation
strength of a single anchor is still controversial. Nery and
colleagues22 reported 38 consecutive cases of CLAI treated
by all-inside arthroscopic Broström-Gould surgery with a
single 5.0-mm anchor. After an average follow-up of 9.8
years, only 2 patients (5.3%) had ankle joint complications
(1 case of anterior soft tissue impingement syndrome and 1
case of medial instability of the ankle), but no recurrence of
CLAI.
The current study demonstrated that the all-inside
arthroscopic Broström-Gould surgery significantly
improved the pain and functional scores of the VAS,
AOFAS, KAFS, and FAOS in both the single-anchor group
and the double-anchor group. This finding is in agreement
with the conclusions of the above-discussed investigations.
Interestingly, while there was no significant difference in
VAS and AOFAS functional scores between the 2 groups,
the KAFS and FAOS in the double-anchor group were sig-
nificantly higher than those scores in the single-anchor
group. Although the AOFAS score is currently the most
commonly used clinical score for evaluating patients under-
going foot and ankle surgery, it has never been evaluated for
validity and reliability to assess ankle instability.6 AOFAS
is a clinical scoring system based on clinician observation,
which is mainly used for evaluating the patient’s pain, func-
tion, and alignment. AOFAS mainly focuses on evaluation
6 Foot & Ankle International 00(0)
of the patient’s pain, with less emphasis on evaluation of
joint stability.15 As long as the patient has no pain and a
normal range of motion after surgery, even if they have a
subjective feeling of ankle instability, the patient can still
achieve a full score of 100. Since the VAS and AOFAS scor-
ing systems focus mostly on the subjective evaluation of
joint pain, it can be concluded that the number of anchors
used in the Broström-Gould procedure does not affect post-
operative joint pain.
In order to strengthen our data analysis, the KAFS and
FAOS were also used to evaluate postoperative results. In
contrast, the KAFS and FAOS scoring systems, being func-
tional scales, mainly focus on the objective assessment of
ankle motion function and stability. These 2 validated
patient-reported outcome scale systems have been recom-
mended by a recent official statement from the AOFAS.16
The KAFS and FAOS are important parameters for evaluat-
ing the stability and function of the ankle joint. They are
evidence-based options to evaluate outcome after CLAI
surgical treatment. Therefore, we believe that the KAFS
and FAOS are more accurate for evaluating the stability of
the ankle joint. The presented data indicate that all-inside
arthroscopic Broström-Gould surgery with double-anchor
fixation results in a significantly higher KAFS and FAOS
than single-anchor fixation. Although there is a statistically
significant improvement in the KAFS and FAOS, we need
to pay attention to the possible presence of differences
between statistical and clinical significance. The smallest
amount of change in score that can be considered meaning-
ful from the patient perspective is defined as the minimal
clinically important difference.14 The minimal clinically
important difference is the smallest-value score that indi-
cates real change and not just a measurement error.
The exercise participation rate of patients after CLAI
repair is a very important indicator of the benefits of the
surgery. Regaining their preinjury level of physical activity
and exercise is essential for patients’ functional recovery
and self-confidence building.26 Strong ligament fixation in
patients with CLAI allows them to engage in functional
exercises after surgery since recurrent lateral instability of
the ankle joint is still one of the main factors responsible for
the inability of the patients to resume normal activities.24
The data obtained here demonstrate that the exercise par-
ticipation rate was significantly higher in the double-anchor
group than in the single-anchor group. Based on the current
results and above-discussed studies, it appears that the rate
of restoration of motion is related to the number of anchors
used to stabilize the ATFL, with double anchors providing
greater functional stability.
The use of double anchors may also be associated with
negative outcomes that should be addressed in future stud-
ies, for example, whether an increase in the number of
anchors will increase the risk of suture reaction or implant
rejection, although no suture reaction or implant rejection
was observed in the present study. Some limitations inher-
ent in the current work should be acknowledged, such as the
possible presence of differences between statistical and
clinical significance, and not addressing the potential
impact of anchor diameter and the number of anchor sutures
on the fixation effect and postoperative function. Another
limitation was that, as a retrospective cohort study, there
was a patient selection bias. This limitation was compen-
sated for, to some extent, because all of the procedures were
performed by the same senior surgeon, all outcomes were
evaluated by an experienced ankle surgeon, and the postop-
erative functional exercise was performed under the guid-
ance of a rehabilitation specialist. As experience in the use
of all-inside arthroscopic Broström-Gould surgery contin-
ues to grow, these issues undoubtedly will be addressed.
Conclusion
Compared with single-anchor fixation, double-anchor fixa-
tion showed better functional outcomes in the all-inside
arthroscopic Broström-Gould surgery for patients with
CLAI. The KAFS and FAOS were significantly higher and
the rate of return to play was significantly higher with dou-
ble-anchor fixation. However, patients did not subjectively
notice a difference between single and double anchors.
Editor’s Note
The authors are to be congratulated for furthering our knowledge
regarding arthroscopic lateral ankle ligament repair. However, it is
unclear what selection bias existed since the patients self-selected
whether they received 1 or 2 suture anchors.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this arti-
cle. ICMJE forms for all authors are available online.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Shi-Ming Feng, MD, https://orcid.org/0000-0002-0815-2426
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