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C OPYRIGHT Ó 2009 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Chondral Injuries of the Ankle with Recurrent Lateral

Instability: An Arthroscopic Study
By Kazuya Sugimoto, MD, PhD, Yoshinori Takakura, MD, PhD, Koujiro Okahashi, MD, PhD, Norihiro Samoto, MD,
Kenji Kawate, MD, PhD, and Makoto Iwai, MD, PhD

Investigation performed at the Department of Orthopaedic Surgery, Saiseikai Nara Hospital, Nara-shi, Nara, Japan

Background: Prolonged lateral instability of the ankle after ligament injury has been believed to be a major cause of
osteoarthritis of the ankle, yet the rate of development of osteoarthritis of the ankle is relatively low. Clarifying the
relationship between patient factors and chondral damage of the ankle with prolonged instability is essential to identify the
important risk factors underlying osteoarthritis of the ankle.
Methods: Arthroscopic examination was performed to assess the condition of the articular cartilage in a series of
patients with prolonged lateral instability of the ankle. There were ninety-three patients with ninety-nine involved ankles.
Their mean age was 28.7 years (range, fifteen to fifty-nine years). The relationships between the severity of the chondral
damage and patient factors, the number and combination of torn ligaments, and mechanical instability and alignment of
the ankle mortise were studied.
Results: Twenty-three ankles were classified as grade 0 (normal cartilage); thirty-five, as grade 1 (superficial softening,
fibrillation, or fissuring of the cartilage); twenty-four, as grade 2 (a cartilage defect without exposure of the subchondral
bone); and seventeen, as grade 3 (exposure of the subchondral bone). Patient age, the talar tilt angle, and varus inclination
of the ankle plafond were significantly associated with more severe chondral changes.
Conclusions: Patient age, the talar tilt angle, and varus inclination of the ankle are risk factors for severe chondral
damage of the ankle in patients with a prolonged history of lateral ankle instability.
Level of Evidence: Prognostic Level IV. See Instructions to Authors for a complete description of levels of evidence.

A
n acute inversion sprain of the ankle is sometimes
accompanied by an (osteo)chondral lesion or a bone
bruise1-3. Most such lesions are asymptomatic and heal
well following healing of the injured ligament(s), but a few
become symptomatic. Osteochondral lesions and bone bruises
are easily detected with magnetic resonance imaging, but le-
sions limited to the cartilage without an osseous injury are
poorly detected with this modality. Recurrent minor chondral
injuries are believed to be a cause of degenerative osteoarthritis
when instability of the ankle is prolonged after inappropriate
treatment4.
In 1993, Taga et al. reported that chondral lesions were
detected with arthroscopy in fourteen (88%) of sixteen ankles
with an acute injury of the lateral ligaments and in twenty-four
(92%) of twenty-six ankles with recurrent lateral instability 2.
Van Dijk et al. reported that an acute injury to the articular
cartilage was detected in twenty (67%) of thirty consecutive
patients with an acute rupture of the lateral ligaments3. Van
Dijk et al. reported that typical lesions were located at the tip of
the medial malleolus, whereas Taga et al. did not note lesions in
that area.
Rupture of the lateral ligaments is the most common
injury of the ankle. It has been estimated that there is about
one inversion injury of the ankle per 10,000 people each day,
and persistent functional instability of the ankle develops in
approximately 20% of those with acute complete tears of the
lateral ligaments5.
Harrington reported that prolonged instability of the
ankle was a cause of osteoarthritis of the ankle4. However, the
number of patients in whom osteoarthritis of the ankle even-
tually develops is relatively small compared with the number of
patients with persistent ankle instability. It seems that residual

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a
member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial
entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice,
or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

J Bone Joint Surg Am. 2009;91:99-106 d doi:10.2106/JBJS.G.00087

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instability after an ankle sprain does not always lead to osteo-

arthritis of the ankle. TABLE I Distribution of Chondral Injuries
Some factors are suspected to accelerate the process of No. of Ankles
osteoarthritis. Epidemiologic studies are important for identi-
fying such factors and defining the probability of osteoarthritis Grade Grade Grade Grade Grade 1,
0 1 2 3 2, or 3
of the ankle after an ankle sprain. However, such studies require
huge populations of patients with ankle sprains and long follow- Tibial plafond
up periods of at least ten years because osteoarthritis of the ankle Tip of the medial 42 18 25 14 57
due to ankle sprain develops slowly, sometimes not until more malleolus
than twenty years after the first sprain in our experience. Such a Medial corner 57 25 11 6 42
long-term study is not feasible in our practice. Central and 95 3 1 0 4
In the present study, we evaluated a group of patients lateral areas
with recurrent instability of the ankle, in whom osteoarthritis Talar dome
of the ankle was the most likely to develop. The purpose of the Medial corner 64 24 9 2 35
study was to determine the prevalence, location, and severity of Central and 78 17 4 0 21
the chondral damage accompanying recurrent instability of the lateral areas
ankle and to identify risk factors for the development of os-
teoarthritis of the ankle.
current lateral instability just before the surgical repair of the
Materials and Methods ligaments in Saiseikai Nara Hospital. After exclusion of four

F rom January 1996 to June 2007, arthroscopy was per-

formed in 107 consecutive ankles in 101 patients with re-
patients who were less than fifteen years old and four patients
with osteochondral lesions of the talus detected by magnetic
resonance imaging, there were forty male and fifty-three fe-
male patients. The mean age of the patients was 28.7 years
(range, fifteen to fifty-nine years). Ankles showing narrowing
of the joint space on a standing ankle radiograph at the first
examination were not included in this study. However, in five
patients who delayed having surgery for two to five years after
the first examination, mild narrowing of the ankle joint de-
veloped medially prior to the operation. Sixty-two ankles were
injured during sports activity; thirteen, in a fall on steps or
uneven ground; three, in a fall from a height; and two, in a
motorcycle collision. For nineteen ankles, the patient did not
recall how the sprain occurred. The mean time from the injury
to the arthroscopy was six years and two months (range, six
months to thirty years). No patient had undergone operative
treatment for the sprained ankle, and the details regarding how
they were treated conservatively prior to consulting us were
usually unavailable.
The diagnosis of recurrent lateral instability of the ankle
was based on a history of inversion sprains and the findings on
physical examination and stress radiography. Stress radiogra-
phy was used to measure the anterior drawer distance on an-
terior drawer stress and the talar tilt angle on inversion stress6,7.
Positive findings on stress radiography, defined as a talar tilt
angle of ‡7° or an anterior drawer distance of ‡4 mm, was
critical to making a diagnosis of recurrent lateral instability of
the ankle. The stress radiography was done with use of a Telos
apparatus (Telos, Marburg, Germany) with an applied stress
of 15 kPa8. The mean talar tilt angle (and standard deviation)
was 14.3° ± 6.1° (range, 5° to 32°), and the mean anterior
drawer distance was 7.5 ± 2.6 mm (range, 3 to 15 mm). Some
patients showed a talar tilt of <7° or an anterior drawer dis-
Fig. 1 tance of <4 mm because either a talar tilt of ‡7° or an anterior
The inclination of the tibial plafond. A = TAS angle, B = TBM angle, and drawer distance of ‡4 mm was required to meet the inclusion
M = TMM angle. criteria.
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Fig. 2-A
Fig. 2-C
Narrowing of the ankle joint space at the medial gutter on
a standing ankle radiograph was noted in seven ankles in five
patients, and these ankles were classified as having stage-II
osteoarthritis according to the system of one of us (Y.T.) and
colleagues9. Narrowing of the ankle joint space was not de-
tected on the standing ankle radiographs of the other ninety-
two ankles, and these ankles were classified as having stage-I
osteoarthritis. The indication for operative treatment was
recurrent giving-way or a feeling of apprehension with pain
after conservative treatment consisting of peroneal muscle
training and wearing of a soft elastic brace for at least three
months.
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Fig. 2-B
Figs. 2-A, 2-B, and 2-C Chondral injuries at the three major locations.
Fig. 2-A A grade-2 lesion at the tip of the medial malleolus. MM = medial
malleolus, G = medial gutter, and T = talus. Fig. 2-B A grade-2 lesion of the
medial corner of the talus. TP = tibial plafond, and TD = talar dome. Fig.
2-C A grade-3 lesion of the medial corner of the tibia. AM = anteromedial
edge of the tibial plafond, and TD = talar dome.
Subtalar arthrography was performed under image inten-
sification in ninety-one ankles in eighty-three patients; 3 to 4 mL of
iotrolan (Isovist 240) was injected posterolaterally, and antero-
posterior, lateral, and oblique radiographs were made10,11. Magnetic
resonance imaging was performed in twenty-one ankles that were
painful even when the patient was standing on a flat surface (in
addition to the four ankles that were found to have an os-
teochondral lesion of the talus and were excluded from the study).
Arthroscopy was performed with the patient under gen-
eral or lumbar spinal anesthesia just before surgical repair of the
ligaments. The patients were positioned in a semilateral decu-
bitus position with the affected side up12. This position allowed
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TABLE II Comparison of Patient Characteristics According to the Cartilage Condition of the Ankle

Grade 0 Grade 1 Grade 2 Grade 3 P Value

Total no. of ankles 23 35 24 17 —

Sex (no. of ankles) <0.01*
Men 13 18 9 2 —
Women 10 17 15 15 —
Age† (yr) 20.2 ± 7.7 25.9 ± 10.4 32.5 ± 11.2 39.9 ± 13.8 <0.001‡
(15-46) (15-56) (16-56) (16-59)
Body mass index† (kg/m2) 23.2 ± 2.1 21.8 ± 2.6 23.0 ± 3.1 23.5 ± 3.5 0.268‡
(19.1-27.0) (17.2-27.4) (18.4-31.3) (18.1-29.5)
Mechanical instability† —
Talar tilt angle (deg) 12.1 ± 4.7 12.8 ± 6.1 16.2 ± 5.4 17.9 ± 6.7 <0.01‡
(5-22) (5-32) (5-26) (7-30)
Anterior drawer distance (mm) 6.5 ± 2.2 7.5 ± 2.5 8.3 ± 2.7 7.8 ± 2.7 0.123§
(3-12) (3-14) (5-13) (4-15)
Inclination of tibial plafond† —
TAS angle (deg) 86.8 ± 1.5 87.4 ± 2.0 87.7 ± 2.1 84.1 ± 3.8 <0.001§
(84.5-90) (84-93) (84-91) (76-90)
TBM angle (deg) 74.8 ± 2.7 74.4 ± 2.7 75.5 ± 3.3 72.5 ± 3.8 0.0944‡
(71-81) (67-79) (70-82) (66-78)
TMM angle (deg) 28.8 ± 3.5 26.5 ± 4.5 27.7 ± 4.5 33.1 ± 7.5 <0.01‡
(22-35) (18-35) (18-34) (17-45)
Arthrographic findings# —
Communication of ankle and 5/23 13/32 17/24 8/12 <0.001*
subtalar joints
Leakage to peroneal tendon sheath 3/23 5/32 12/24 5/12 <0.01*
Presence of lateral recess 2/23 12/32 7/24 4/12 <0.001*
Leakage to sinus tarsi 5/23 11/32 11/24 5/12 0.0953*
Absence of micro-recess 4/23 8/32 11/24 5/12 0.187*
Combination of torn ligaments (no.) <0.001*
Isolated anterior talofibular 20 22 7 5 —
ligament injury
Combined anterior talofibular and 3 13 17 12 —
calcaneofibular ligament injuries
Presence of os subfibulare# 9/23 7/35 6/24 3/17 0.183*
Duration of symptoms† (mo) 41.0 ± 45.9 65.1 ± 68.8 96.1 ± 104.2 103.7 ± 117.3 0.166‡
(6-192) (6-266) (6-360) (6-360)

*According to the Mann-Whitney U test. †The values are given as the mean and standard deviation, with the range in parentheses. ‡According to
the Kruskal-Wallis test. §According to one-factor analysis of variance. #The values are given as the number with the finding/number examined for
the finding in the group.

both arthroscopy and surgical repair of the ligaments. For the
arthroscopy, the patients were positioned with the hip joint in
extension and external rotation and the knee in extension, and
then the surgical repair of the ligaments was performed with
the hip joint in flexion and internal rotation and the knee in
flexion. The condition of the ligaments was confirmed through
a reverse L-shaped capsulotomy incision13. Fifty-four ankles
revealed an isolated injury of the anterior talofibular ligament,
and forty-five had a combined injury of the anterior talofibular
and calcaneofibular ligaments. No ankle had an isolated injury
of the calcaneofibular ligament.
An additional distal tibial osteotomy was performed with
an opening wedge technique and an iliac bone graft on the
medial side of five ankles of four patients with marked varus
inclination of the tibial plafond. Osteochondral lesions of the
talus were treated with mosaicplasty in four ankles and with
drilling in one.
A 2.7-mm arthroscope was introduced through a stan-
dard anteromedial portal, and a five-point examination was
done with a focus on the medial gutter and the tip of the medial
malleolus, the medial corner, the central talar dome, the tri-
furcation area, and the anterolateral aspect of the joint capsule.
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TABLE III Effect of Patient Characteristics as Well as Parameters of Ligament Injuries on Severity of Chondral Injuries of the Ankle*

Odds Ratio 95% Confidence Interval P Value

Age
Group 0 1.00†
Group 1 1.06 0.97 to 1.16 0.19
Group 2 1.10 1.00 to 1.21 <0.05
Group 3 1.14 1.03 to 1.27 <0.05
Female sex
Group 0 1.00†
Group 1 0.94 0.28 to 3.16 0.92
Group 2 1.45 0.32 to 6.51 0.63
Group 3 2.50 0.30 to 20.95 0.40
Body mass index
Group 0 1.00†
Group 1 0.77 0.59 to 1.01 0.51
Group 2 0.95 0.70 to 1.30 0.75
Group 3 1.03 0.72 to 1.50 0.85
Duration of symptoms
Group 0 1.00†
Group 1 1.00 0.99 to 1.02 0.73
Group 2 1.01 0.99 to 1.02 0.44
Group 3 1.00 0.99 to 1.02 0.67
Mechanical instability
Talar tilt angle
Group 0 1.00†
Group 1 0.98 0.85 to 1.13 0.77
Group 2 1.07 0.91 to 1.24 0.42
Group 3 1.28 1.04 to 1.58 <0.05
Anterior drawer distance
Group 0 1.00†
Group 1 1.17 0.86 to 1.58 0.31
Group 2 1.16 0.83 to 1.61 0.39
Group 3 1.12 0.75 to 1.67 0.57
Inclination of tibial plafond
TAS angle
Group 0 1.00†
Group 1 1.15 0.84 to 1.56 0.38
Group 2 1.14 0.79 to 1.64 0.49
Group 3 0.63 0.40 to 0.99 <0.05
Combined anterior talofibular and calcaneofibular
ligament injuries
Group 0 1.00†
Group 1 2.15 0.42 to 11.10 0.36
Group 2 6.99 1.13 to 43.33 <0.05
Group 3 1.79 0.18 to 17.66 0.62
Presence of os subfibulare
Group 0 1.00†
Group 1 0.48 0.12 to 1.88 0.29
Group 2 1.22 0.22 to 6.74 0.82
Group 3 1.67 0.10 to 28.01 0.72

*An odds ratio of >1 indicates that the patients in the category were more likely to have severe chondral injuries than was the baseline group.
†The baseline value.
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In the trifurcation area, the lateral area of the tibial plafond, the
lateral corner of the talar dome, and the fibula were examined14.
No traction device was used to distract these relatively unstable
joints. Any changes in the cartilage such as softening, fibril-
lation, fissuring, or ulceration were examined by probing, and
the depth of the chondral lesion was confirmed. The surgeons,
including one of us (K.S.), graded the cartilaginous surface. The
ankles were classified according to the severity of the chondral
damage as grade 0 (no lesion), grade 1 (superficial softening,
fibrillation, or fissuring), grade 2 (a chondral defect without
exposure of the subchondral bone), or grade 3 (exposure of or a
defect in the subchondral bone)12.
Patient age, sex, and body mass index; the duration of
symptoms; the severity of mechanical instability (as measured
by the talar tilt angle and the anterior drawer distance); the
combination of ligaments injured; the inclination of the tibial
plafond; and the presence of an os subfibulare were compared
among the four groups of ankles classified according to the
condition of the cartilage. The inclination of the tibial plafond
was evaluated with use of three angles measured on the an-
teroposterior ankle radiograph (Fig. 1): (1) the TAS angle,
which is the angle between the tibial shaft and its distal joint
surface; (2) the TBM angle, which is the angle between the
tibial shaft and a line connecting the tips of both malleoli; and
(3) the TMM angle, which is the angle between the tibial shaft
and the joint surface of the medial malleolus9,15. A TAS angle of
<90° represented varus angulation of the tibial plafond. A
small TBM angle or a large TMM angle was also considered to
represent varus angulation of the tibial plafond.
Data Analysis
The patient characteristics and the parameters related to the
ankle sprain were compared among the four groups of patients
classified according to the condition of the cartilage. Parametric
and nonparametric statistical analysis was employed to com-
pare the groups. Significant differences between groups were
determined with one-factor analysis of variance, the Kruskal-
Wallis test, and the Mann-Whitney U test. A p value of <0.05
was considered significant. The Mann-Whitney U test was used
to compare sex, the arthrographic findings, the combinations of
torn ligament(s), and the presence of an os subfibulare among
the groups; the Kruskal-Wallis test was used for the group
comparisons of age, body mass index, the talar tilt angle, the
TBM angle, the TMM angle, and the duration of symptoms;
and one-way analysis of variance was used for the group com-
parisons of the anterior drawer distance and the TAS angle.
Multiple logistic regression analysis was then performed in an
attempt to identify which factors were related to the presence of
advanced chondral injuries. The regression coefficients were
converted into odds ratios, which can be considered as means of
the relative risks. An odds ratio of >1 indicates that patients in a
given category were more prone to have severe chondral
injuries.
Source of Funding
There was no source of funding for this study.
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Results
C hondral lesions were detected with arthroscopy in seventy-
six (77%) of the ninety-nine ankles. Twenty-three ankles
were classified as grade 0; thirty-five, as grade 1; twenty-four, as
grade 2; and seventeen, as grade 3. The locations and grades of
the lesions are summarized in Table I. Fifty-seven lesions were
located at the tip of the medial malleolus; forty-two, in the
medial corner of the tibia; thirty-five, in the medial corner of
the talus; and twenty-five, in the central and lateral area of the
joint; the majority of the lesions were located in the medial half
and the anterior two-thirds of the joint (Figs. 2-A, 2-B, and
2-C). Seventeen of the forty-two chondral lesions on the tibial
side of the medial corner and eleven of the thirty-five chondral
lesions of the talus in the medial corner were classified as grade
2 or 3. In contrast, only five lesions in the central and lateral
area were classified as grade 2, and no lesion in that area was
classified as grade 3.
The results of the comparisons of the patient groups ac-
cording to age, sex, body mass index, and duration of symptoms
are summarized in Table II. The mean age of the patients in-
creased as the grade of the severity of the cartilage lesion in-
creased, and the differences between the groups were significant.
The sex distribution was nearly even in the grade-0, 1, and
2 groups. In the grade-3 group, the proportion of women was
much greater than that of men. Neither the body mass index
nor the duration of symptoms differed among the groups. The
mean duration of symptoms was greater in the grade-3 group,
but this difference was not significant.
The group comparisons according to the various ankle
joint parameters are also summarized in Table II. The mean
talar tilt angle on stress radiography increased significantly
with the severity of the grade of the lesion. The anterior drawer
distances did not differ significantly among the groups. The
frequency of a communication between the ankle and subtalar
joint cavities as demonstrated on subtalar arthrography was
significantly different among the groups, as was the combi-
nation of torn ligaments. Rupture of the calcaneofibular liga-
ment had a relationship with the severity of the cartilage lesion.
On the other hand, the presence of an os subfibulare was not
related to the grade of the cartilage lesion. Inclination of the
tibial plafond as represented by the TAS and TMM angles was
significantly related to the grade of the chondral lesion.
The results of the multiple logistic regression analysis are
summarized in Table III. The age of the patients and the talar
tilt angle showed odds ratios of >1 with confidence intervals
not including 1.0, and the TAS angle showed an odds ratio of
<1 with a confidence interval not including 1.0, for grade-3
ankles when the baseline was set as group 0. The sex of the
patients, rupture of the calcaneofibular ligament, and the pres-
ence of an os subfibulare had odds ratios of >1.5, but the
confidence intervals included 1.0.
Discussion
S everal reports have focused on arthroscopic findings in ankles
with chronic or recurrent ankle instability 2,3,16-18. We believe
that Taga et al. were the first to identify a high prevalence of
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chondral lesions in ankles with recurrent lateral instability with
the use of arthroscopy 2. They showed that moderate chondral
lesions typically were located in the medial half of the joint.
However, in that study, arthroscopy was performed with use of a
4.0-mm arthroscope, and lesions located at the tip of the medial
malleolus were not examined. Recent reports have also shown a
high prevalence of focal chondral lesions in the medial half of
the ankle with chronic instability 17,18. Van Dijk et al. noted that
chondral lesions in ankles with an acute inversion sprain were
typically found at the tip of the medial malleolus3.
In the current study, chondral lesions of the ankle were
detected in seventy-six (77%) of the ninety-nine ankles, and
lesions at the tip of the medial malleolus were detected in fifty-
seven ankles (58%), findings that affirm those of the previous
reports. Most of the lesions were located in the medial half of
the ankle, especially in the medial corner and medial gutter.
In our opinion, the chondral lesions in these ankles with
recurrent or chronic instability were a combination of acute
chondral injuries and subsequent degenerative changes. Some
of these lesions could have been present prior to the time of the
sprain. Harrington reported that recurrent instability after an
inversion sprain was a cause of osteoarthritis of the ankle4.
However, osteoarthritis with narrowing of the joint space does
not always develop in ankles with recurrent instability. Osteo-
arthritis seems to develop in some ankles with chondral
damage and not in others. The severity of the sprain and the
period of prolonged instability are generally considered to be
factors accelerating the development of osteoarthritis, but this
has not been confirmed in the literature.
In the current study, the duration of symptoms did not
affect the grade of the chondral damage, whereas the age of the
patient did. These results are compatible with our previous
finding that long-term osteoarthritic changes of the ankle after
a Watson-Jones tenodesis had no relationship with the pre-
operative duration of symptoms but rather were related to the
age of the patient at the time of the operation19.
Katsui et al. reported that female sex, a history of re-
current sprains, and the inclination of the tibial plafond were
possible factors in the development of osteoarthrosis of the
ankle20. One of us (Y.T.) and colleagues reported that a valgus
distal tibial osteotomy was effective in treating osteoarthritis
located in the medial half of the ankle9. In the current study,
varus inclination of the tibial plafond was seen in ankles with
a grade-3 chondral lesion and was considered to be a factor
accelerating the chondral degeneration4.
The logistic regression analysis showed only a few varia-
bles for which the confidence interval did not include a value of
1.0. In our opinion, if the series had included all stages of ankle
arthritis, the confidence intervals might have shifted away from
1.0. However, this study principally focused on ankles with
recurrent instability without narrowing of the joint space on
standing radiographs, and all but seven ankles in the study were
classified as having stage-I osteoarthritis.
The rate of calcaneofibular ligament insufficiency dif-
fered among the lesion grades. Stress radiography is usually
used to evaluate dysfunction of the anterior talofibular and/or
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the calcaneofibular ligament21,22. The talar tilt angle is consid-
ered to be a parameter of dysfunction of the calcaneofibular
ligament, and the anterior drawer distance is thought to be
related to injury of the anterior talofibular ligament. The talar
tilt angle was related to the severity of the chondral lesions in
this study. Instability of the ankle is not always detected by stress
radiography. The instability detected by stress radiography is
termed mechanical instability, and that not detected by stress
radiography is termed functional instability 23. Mechanical in-
stability might not represent the true rate of instability of the
ankle, and the reliability of this definition is unknown. Intra-
class reproducibility of the stress radiography with use of the
Telos apparatus was not tested in our hospital. However, this
has been one of the most common methods used to determine
mechanical instability.
In this study, older age, a larger talar tilt angle, and varus
inclination of the tibial plafond were identified as risk factors for
the development of osteochondral lesions after an inversion sprain
of the ankle. Of these factors, mechanical instability of the ankle
and inclination of the tibial plafond are surgically correctable.
This study had some limitations. Patients who underwent
reconstruction of the lateral ankle ligament(s) were the focus of
the investigation. This was not a random sampling from the
population of patients with recurrent instability of the ankle
because we did not include patients who were treated conser-
vatively or patients with progressive osteoarthritis of the ankle.
Also, for ethical reasons, we did not perform arthroscopy on
patients treated conservatively or those without symptoms. De-
spite these limitations, it is still valuable to know the risk factors
for cartilage dysfunction in a symptomatic ankle requiring re-
construction of the lateral ankle ligament(s).
In conclusion, chondral lesions were detected in most of
the ankles with recurrent or chronic lateral instability. The lesions
were usually located in the medial half of the joint, and the se-
verity of the lesions was related to patient age, the talar tilt angle,
and varus inclination of the tibial plafond. Although prolonged
instability does not always lead to osteoarthritis of the ankle, these
risk factors may be important ones to consider in the patho-
genesis of ankle arthritis following an inversion sprain. n
Kazuya Sugimoto, MD, PhD
Koujiro Okahashi, MD, PhD
Makoto Iwai, MD, PhD
Department of Orthopaedic Surgery, Saiseikai Nara Hospital, 4-643
Hachijo, Nara-shi, Nara 6308145, Japan. E-mail address for K. Sugimoto:
kzort@m3.kcn.ne.jp
Yoshinori Takakura, MD, PhD
Kenji Kawate, MD, PhD
Department of Orthopaedic Surgery, Nara Medical University,
840 Shijo-cho, Kashihara, Nara 634 8521, Japan
Norihiro Samoto, MD
Department of Orthopaedic Surgery, Nara Prefectural Hospital,
1-30-1, Hiramatsu, Nara-shi, Nara 631 0846, Japan
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T H E J O U R N A L O F B O N E & J O I N T S U R G E RY J B J S . O R G
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