The clinical outcome of anatomical reconstruction or tenodesis in the treatment of chronic anterolateral ankle instability was assessed in a retrospective multicenter study. The anatomical reconstruction group (group A) consisted of 106 patients (mean age at operation 24 +/- 8.4 years) and the tenodesis group (group B) of 110 patients (mean age at operation 26 +/- 11.4 years). Patients were evaluated at a mean follow-up of 5.5 +/- 2.8 years in group A and 5.2 +/- 2.9 years in group B. The review protocol included patient characteristics, physical examination, two ankle scoring scales to evaluate the functional results, and standard anteroposterior and lateral radiographs to evaluate degenerative changes. Mechanical stability was evaluated using standardized stress radiographs. A larger number of reoperations was performed in group B (P = 0.008). At physical examination, more patients in group B had a smaller range of ankle motion than those in group A (P = 0.009). A larger proportion of patients in group B had medially located osteophytes, as seen on standard radiographs (P = 0.04). On stress radiographic examination, the mean talar tilt (P = 0.001) and mean anterior talar translation (P < 0.001) were seen to be significantly greater in group B than in group A. There were no differences in mean Karlsson score between the groups, but more patients in group A had an excellent result on the Good score (P = 0.011). Unlike anatomical reconstructions, tenodeses do not restore the normal anatomy of the lateral ankle ligaments. This results in restricted range of ankle motion, reduced long-term stability, an increased risk of medially located degenerative changes, a larger number of reoperations, and less satisfactory overall results.

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The evolution of operations to repair or substitute the anterior cruciate ligament is summarized for the period 1903 to the present. The increase in the understanding of the function of the ligament is described and in the light of this experience a programme for the management of these lesions is suggested. In acute lesions in a young sportsman the loss of the stability provided by the central pivot prevents competition at high level and operation to repair, substitute, or reinforce the ligament is recommended. In the older athlete non-intervention may be acceptable in view of the knowledge that the adverse mechanical consequences of a rupture of the ACL may be lessened by appropriate rehabilitation. Such measures may be successful for a couple of years, but usually, within five years, functional symptoms will appear. In patients who are middle aged, or those with no competitive need, rehabilitation only is usually adequate, and surgical reconstruction is rarely necessary. In chronic lesions operation should probably only be undertaken when instability is a notable problem. Reconstruction may be accomplished by an autograft using a bone patella bone, semi-membranosis or semi-tendonosis transfer, allograft substitution or a prosthesis.

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