Additional cartilage treatment for small defects in chronic ankle instability shows no mid-term benefit and delays recovery: a randomized controlled trial.

Abstract

Background: The presence of chondral lesions in patients with chronic ankle instability is common and has been suggested as a possible cause of persistent pain in some cases, even after successful ligament reconstruction. For this reason, some authors have proposed combining ankle stabilization with cartilage microfracture; however, the results reported in literature are contradictory.

Materials and methods: The study was designed as a prospective randomized clinical study with two parallel arms. Patients with an anterior talofibular ligament tear causing pain and instability, associated with a Berndt-Harty stage I-IIb talar osteochondral lesion of < 150 mm² that had not responded to conservative treatment, were blindly assigned to either isolated ligament reconstruction (REC) or reconstruction plus microfracture (REC + MIC). Evaluators were also blinded.

Results: A total of 71 patients were included in the study, with 36 in the REC group and 35 in the REC + MIC group. The groups were comparable in terms of anthropometry and pathology. The operating time was significantly longer in the REC + MIC group (48.0 ± 4.5 min) compared with the REC group (24.9 ± 3.9 min; p < 0.001). At the end of follow-up, both patient groups showed similar results on the American Orthopaedic Foot and Ankle Society (AOFAS) score (p = 0.755), Self-Reported Foot and Ankle Score (SEFAS) (p = 0.862), Karlsson score (p = 0.993), and visual analog scale (VAS) (p = 0.870). However, the time to recovery differed between the groups, with patients in the REC group recovering faster from before the operation (pre-op) through the third month after the operation (post-op). The difference in recovery at 3 months post-op was statistically significant on the AOFAS (p < 0.001), SEFAS (p < 0.001), and Karlsson (p < 0.001) scores. No statistically significant difference was observed in terms of pain (p = 0.342). The failure rate was also comparable between the groups, with four (11.1%) reoperations in the REC group and five (14.3%) in the REC + MIC group (p = 0.735).

Conclusions: At 2 years post surgery, no differences were observed in function (according to the AOFAS, SEFAS, and Karlsson scores), pain, or complications in patients with ankle instability and associated chondral damage treated with or without microfractures. However, patients who underwent microfractures experienced a significantly slower recovery of function.

Level of evidence: Level 1.

Trial registration: ClinicalTrials.gov Identifier NCT06947317 (retrospectively registered). Date: 1 May 2025. ( https://clinicaltrials.gov/study/NCT06947317 ).