Clinical trial comparing two surgical techniques used to treat instability of the ankle in those people who are normally involved in sports activities.

The operation is performed with the patient under a general anaesthetic in an operating theatre. An examination under anaesthesia is performed and a diagnostic arthroscopy using two standard portals. The LARS procedure is performed using an anterolateral incision and approach to the ankle, similar to primary incision and approach to that used for the MBG procedure, with two additional 1cm incisions. The most distal incision is used to anchor the CFL limb of the LARS to the isometric insertion site on the calcaneum, and the proximal one is used to draw the LARS loop up the fibular tunnel and for individual tensioning of the ATFL and CFL. A 5mm tunnel is drilled in the fibula at the area where the ATFL and CFL attachments overlap, aiming proximally and posteriorly within the centre of the fibula, ensuring that the tunnel is at least 25mm long. A 4.5mm x 20mm blind ending tunnel is drilled at the distal insertion sites of the ATFL and CFL. A separate 1cm capsulotomy is performed at the insertion site of the ATFL so that the ATFL limb of the LARS will run in an extra-capsular location, while the CFL limb of the LARS will run from the distal insertion site deep to the peroneal tendons and capsule, again in an extracapsular location. Both limbs of the LARS are secured to their respective insertion sites using a 4.75 suture anchor (BioComposite SwiveLock, Arthrex Inc). Once the loop of the LARS is passed from distal to proximal along the fibular tunnel it can be retrieved via the most proximal incision the two limbs tensioned individually to create a stable ankle, and then secured using a third 4.75 mm SwiveLock. The excess loop is then excised flush with the posterior surface of the fibula. A simple repair of the LCL complex is then performed using absorbable suture (1-vicryl) with imbrication of the attenuated structure, before closing the wound in layers. The surgery take approximately 70 minutes to perform. All patients are placed in a dorsal back slab until 7-10 days post-surgery. At this first post-operative review the wound is checked and the patients placed in a sub-talar stabilizing brace. The patient is allowed to weight bear as tolerable in the brace, and the rehabilitation program commenced under the supervision of the treating physiotherapist. The rehabilitation protocol aimed to return patients to full activity within 3-4 months of surgery. The surgery is performed by the main author / researcher as described in the study protocol.