Objective To investigate the surgical treatment methods and clinical outcomes of repair for anterior talofibular ligament (ATFL) injury at talar attachment. Methods A clinical data of 26 patients with ATFL injuries at the talar attachment, who underwent surgical treatment between January 2021 and January 2025, was retrospectively analyzed. The cohort comprised 12 males and 14 females, with a mean age of 30 years (range, 11-52 years). The mean body mass index was 21.5 kg/m2 (range, 16.2-28.2 kg/m2). The median disease duration was 6 weeks (range, 4 days to 108 months). Preoperative Numeric Rating Scale (NRS) score was 4.5±1.7 and American Orthopaedic Foot and Ankle Society (AOFAS) score was 58.0±19.1. The anterior drawer test was positive in all cases, and the varus stress test was positive in two cases. Concomitant pathologies included osteochondral lesions of the talus (n=4), calcaneofibular ligament injury (n=2), sinus tarsi syndrome (n=3), and generalized ligamentous laxity (n=2). Arthroscopic repair was performed in 21 patients. Five patients with extensive ATFL avulsions or concomitant calcaneofibular ligament injuries underwent a mini-open procedure. Standardized postoperative rehabilitation was implemented for all patients. Results All incisions achieved primary healing with no surgery-related complication. All patients were followed up 12-59 months (mean, 28 months). At last follow-up, NRS and AOFAS scores improved significantly to 0.8±1.0 and 96.8±5.0, respectively (P<0.05). Mechanical stability was restored, with negative anterior drawer tests in all patients. Regarding functional recovery, 11 patients returned to their pre-injury sports intensity at a mean of 6 months (range, 4-7 months). The remaining 15 patients who had no exercise habits before injury resumed normal daily activities at 6 months after operation, among them, 2 cases exhibited limited range of motion at 6 months but achieved functional independence for daily activities following intensive rehabilitation. Conclusion Surgical repair of ATFL injury at the talar attachment—whether via arthroscopic suture anchors, mini-open suture anchors, or transosseous suturing—yields favorable clinical outcomes. The choice of surgical technique should be stratified by the extent of ligamentous injury and the severity of concomitant pathologies.
