The goal of this clinical trial is to learn if treating only the anterior talofibular ligament (ATFL) tear with ligament repair is as effective as treating both the ligament tear and the associated osteochondral lesion of the talus at the same time in adults with ankle instability and pain.

The main questions it aims to answer are:

• Do patients who undergo both ligament repair and treatment of the cartilage lesion have better clinical and functional outcomes than those who only have the ligament repaired?
• Is there a difference in pain relief, recovery time, and return to physical activity between the two approaches?

Researchers will compare patients who receive isolated ligament repair to those who receive ligament repair plus microfracture surgery to see if treating both injuries provides better results.

Participants will:

• Be randomly assigned to one of the two treatment groups.
• Undergo surgery by the same surgeon.
• Complete questionnaires about ankle function and pain before surgery and at multiple follow-up points.
• Have physical exams and imaging to assess ankle stability and healing.

This randomized controlled trial investigates the clinical relevance of concomitant osteochondral lesions of the talus in patients undergoing surgical treatment for chronic ankle instability (CAI). Despite successful ligament reconstruction, a substantial proportion of patients report persistent pain, possibly due to associated intra-articular pathology. The study aims to determine whether addressing the osteochondral lesion during the same surgical procedure provides additional clinical or functional benefit compared to isolated ligament repair.

Sixty adult patients with symptomatic CAI and a concomitant talar osteochondral lesion (≤150 mm², Berndt-Harty stage I-IIb) were randomly assigned to two parallel groups. Both groups underwent arthroscopic all-inside anterior talofibular ligament (ATFL) repair. In the experimental group, additional curettage and microfracture of the osteochondral lesion were performed. A standardized rehabilitation protocol was followed, with return to sport permitted at three months for the isolated repair group, and four months for the combined intervention group due to the more extensive surgical gesture.

Primary and secondary outcomes were assessed using validated scales (AOFAS, Karlsson, SEFAS, and VAS) at baseline, and at 1, 3, 6, 12, and 24 months postoperatively. The minimum follow-up period was two years. Statistical analysis included mixed ANOVA for repeated measures and adjustment for multiple comparisons. The study was powered to detect clinically significant differences in AOFAS scores between groups, with a sample size of 30 per group allowing for 20% attrition.

This study addresses a current gap in the literature regarding the management of osteochondral lesions in CAI and provides level I evidence to guide treatment decisions in patients with combined ligamentous and chondral pathology.

Inclusion Criteria:

• Patients with an anterior talofibular ligament (ATFL) tear
• Presence of an osteochondral lesion (OCL) <150 mm²
• OCL classified as stage I-IIb according to the Berndt & Harty classification
• Clinical signs of ankle instability
• Pain in the tibiotalar joint
• Incomplete symptom resolution after prior non-surgical treatment
• Age over 18 years

Exclusion Criteria:

• Congenital or post-traumatic bone deformity of the ankle or foot on the affected side
• Previous surgery on the affected limb
• Neuromuscular disorders
• Generalized joint hyperlaxity (Beighton Score)
• Medial ankle instability (due to deltoid ligament injury)
• Presence of OCL >150 mm²
• Presence of multiple OCLs or other concomitant intra- or extra-articular lesions
• History of ankle fracture
• Lack of signed informed consent
• Body mass index >30 Age under 18 years

De-identified individual participant data (IPD) that underlie the results reported in this article will be made available upon reasonable request to the corresponding author, for purposes of academic and non-commercial research. Requesters will need to provide a methodologically sound proposal and agree to a data access agreement to ensure confidentiality and appropriate use.

Data will be available beginning 6 months after publication of the primary results and will remain available for a period of 5 years.

De-identified individual participant data (IPD) that underlie the results reported in this article will be made available upon reasonable request to the corresponding author, for purposes of academic and non-commercial research. Requesters will need to provide a methodologically sound proposal and agree to a data access agreement to ensure confidentiality and appropriate use.