Knotless Suture Repair For Chronic Lateral Ankle Instability: A Systematic Review and Single-Arm Meta-Analysis

Abstract

Introduction There is a need to assess the use of knotless sutures in cohorts with chronic ankle instability (CAI). Methods A literature search of Embase, Ovid MEDLINE, Cochrane Library and Scopus was conducted from each database’s inception to August 15, 2025. Eligible studies reported patients with CAI undergoing foot and ankle surgery with knotless suture repair. This review was registered in PROSPERO (ID: CRD420251106305). Results A total of 11 studies comprising 476 patients met the eligibility criteria. American Orthopaedic Foot and Ankle Society (AOFAS) scores preoperatively were 63.23 (95% confidence interval [CI]: 60.60-65.86, I 2 = 91%) and at final follow-up were 90.67 (95% CI: 88.09-93.24, I 2 = 96%). Karlsson-Peterson (KP) scores preoperatively were 62.75 (95% CI: 61.16-64.34, I 2 = 79%) and at final follow-up were 88.03 (95% CI: 84.20-91.87, I 2 = 97%). Visual analog scale (VAS) scores preoperatively were 5.80 (95% CI: 4.34-7.25, I 2 = 100%) and at final follow-up were 1.23 (95% CI: 0.74-1.72, I 2 = 96%). Anterior drawer preoperatively was 7.37 mm (95% CI: 5.21-9.53, I 2 = 98%) and postoperatively was 3.12 mm (95% CI: 1.08-5.16, I 2 = 99%). Talar tilt preoperatively was 7.00 0 (95% CI: 3.92-10.08, I 2 = 98%) and postoperatively was 3.11 0 (95% CI: 2.76-3.46, I 2 = 29%). The overall complication rate was 6% (95% CI: 0.03-0.09, I 2 = 57%). The reoperation rate was 2% (95% CI: −0.01-0.03, I 2 = 0%). Conclusion Based on low-quality evidence, knotless repair appears associated with improved functional scores and a low complication rate in this pooled analysis. Direct comparative studies against traditional Broström-Gould knotted approaches are warranted to determine the gold standard in CAI repair moving forward.