Round 1

Reviewer 1 Report

The topic argued is interesting because it is very current in the clinical practice.

Manuscript structure is properly organized, resulting adequate in its contents. All references are correctly reported.

In the text the default character isn’t always respected: authors should correct these lines (e.g., lines 58,61,62,74, 139-142…).

The abstract is complete: all sections of the study are clearly resumed; the aim of the study is comprehensive. 

The introduction is overall well written.

-       At lines 45-47, authors should better report all the surgical indications.

-       Are these indications valid also for the young patients? Or does it exist a minimum age for the surgical approach?

The methodological approach is correct and comprehensive. Sub-sections are globally well described. Images are exhaustive and provide a full comprehension of the text.

-       About surgery, were all interventions performed by the same surgeon?

Results are well presented. Tables and charts are clear and exhaustive.

Discussion is acceptable: comparison with the other studies is clear.

-       Authors should mention the study they talk about, from the lines 218-224.

Author Response

Thank you for taking the time to assess our manuscript and for appreciating the topic and manuscript structure.

We corrected the default character were it wasn’t respected in lines 58,61,62,74, 139-142.

As you suggested we managed to better explain the surgical indications for the procedure we propose in lines 45-49, giving better explanation the residual instability considered a failure of the conservative treatment.

In lines 49-51, it was also specified that young patients can undergo the surgical procedure, in particular in the population considered for the present study the youngest patients were 20 years old when they underwent the surgical procedure.

In line 72 we specified that all the surgical procedures were performed by the same senior surgeon.

In line 144 we corrected an error we made in reporting the age of our patients, as the youngest in our database is at the moment 23 but was 17 years old at the time of surgery.

We apologize for our error and mentioned the study presented form the lines 218-224.

Reviewer 2 Report

The introduction and discussion can be improved. It is written very briefly. The method should be completed.

Author Response

Thank you for your response. We managed to improve the introduction, in particular in lines 45-49 we better explained the instability which we consider a failure of the conservative treatment and therefore a surgical indication. In lines 49-51 we specified that surgery can be proposed also in younger patients, as CAI also affects children and adolescents.

The method was completed by adding that all the surgical procedures were performed by the same Senior Surgeon (line 72).

Reviewer 3 Report

Thanks for giving me the opportunity to review this manuscript.

The authors present a retrospective study of forty-seven patients treated for chronic ankle instability. For this purpose, numerous established PROMS and scores of foot surgery were used in the retrospective evaluation of the clinical outcomes. In principle, this study is well thought out and methodologically sound (even if prospective data would have been desirable).

Return to sport and recurrence rates over longer periods (here 5 years) after minimally invasive reconstruction of the lateral ligament complex using semitendinosus tendon autografts are rarely reported in the literature.

However, the authors could include more relevant literature both in the introduction and in the discussion section, e.g.

Ventura A, Legnani C, Corradini C, Borgo E. Lateral ligament reconstruction and augmented direct anatomical repair restore ligament laxity in patients suffering from chronic ankle instability up to 15 years from surgery. Knee Surg Sports Traumatol Arthrosc. 2020 Jan;28(1):202-207. doi: 10.1007/s00167-018-5244-4. Epub 2018 Oct 30. PMID: 30377717.

Matsui K, Burgesson B, Takao M, Stone J, Guillo S, Glazebrook M; ESSKA AFAS Ankle Instability Group. Minimally invasive surgical treatment for chronic ankle instability: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2016 Apr;24(4):1040-8. doi: 10.1007/s00167-016-4041-1. Epub 2016 Feb 11. PMID: 26869032.

Furthermore, some missing or additional letters and punctuation marks are noticeable in various sections of the manuscript (e.g. at the end of the abstract and the end of the flowchart).

In summary, the authors present solid retrospective research on a relevant issue. Minor revision is necessary for discussion of relevant prior research, and for structure, grammar, and punctuation.

Author Response

We kindly thank you for the attention in reading and reviewing our paper.

We are presenting retrospective data in the present study but we thank you for the suggestion and will consider prospective data for further studies about this topic.

We agree with the reviewer that further literature could be added to our manuscript. In lines 46-49 we better explained the types of instability which we consider a failure of the conservative management and therefore a surgical indication.

We also managed to read and include the interesting articles proposed. The first article was added in line 51 supporting the surgical options viable for CAI, while the second one was included in line 58 concerning the minimally invasive approach.

To conclude, we apologize for the missing punctuation and grammar errors and we hope that after our corrections punctuation marks and grammar are correct.

Reviewer 4 Report

REVIEW of applsci-2182275

Minimally Invasive Reconstruction of the Ankle Lateral Ligament Complex in chronic ankle instability: clinical outcomes, return to sport and recurrence rate at minimum follow up of 5 years

General comments:

This is about the paper of minimally invasive reconstruction of the ankle lateral ligament. It is interesting and helpful for people with the habitual valgus ankle sprained. For example, extreme sports, parachute landing…. Follow up of 5 years to investigate ankle stability is also valuable. However, to assess the recovery effective of ankle function only by using score scale, it was a little weak. Some comments are as follows:

1、I doubt the recruitment process January 2013 to November 2017 137 fifty-four patients. It's more outpatient than recruitment

2、For the rehabilitation of ankle function, the author simply assessed by the VAS, idly a bit evasive. Why not add assessment of foot function, for example plantar pressure, angle of joint movement, gait frequency and step length, etc. So, I don't think it meets the criteria of a research paper unless the appropriate parameters are added to the test

Author Response

Thank you for your interest in the topic and in reading our paper.

In lines 139-141 you can find the number of patients enrolled in the present study, which is due to the high volume of in-patients who come from both northern and southern Italy suffering from a large variety of foot problems in order to be evaluated and treated by the Senior Surgeon who performed the surgical procedures.

We appreciate the reviewer’s insightful suggestion and agree that it would be useful to present the parameters proposed as an assessment of foot function, but the purpose of the present study is to evaluate the clinical outcomes regarding the patients’ ability to return to the sport level they used to have before surgery. Therefore in lines 78-84 we present the PROMs we decided to focus on, such as the AOFAS score, which has a specific part dedicated to foot function, and the Karlsson scoring scale, which considers 8 patient-reported categories including pain, swelling, instability and stiffness.

Round 2

Reviewer 4 Report

• The author has made sufficient revisions and improvements, and I agree to revise the paper for publication

Author Response

Thank you for the insightful suggestions of all the reviewers and for the opportunity to consider our paper for publication.