Anatomical Arthroscopic Anterior Talofibular Ligament Repair and Reconstruction Using a Free Tendon

Abstract

Arthroscopic techniques for anterior talofibular ligament (ATFL) repair and reconstruction have been developed in recent years. We simultaneously performed anatomical arthroscopic ATFL repair and reconstruction using a free tendon graft. The ATFL remnant is carefully dissected only at the footprint of the superior limb of the ATFL, and a bone tunnel is created on each side of the fibula and talus. A soft suture anchor with 2 sets of threads is inserted into the fibular tunnel. One set of threads is used to grab the ATFL remnant via a lasso-loop technique, whereas the other set of threads is used to introduce the ATFL graft. The graft is first fixed with a screw in the talar tunnel. Subsequently, the ATFL remnant and the graft are tightened simultaneously by pulling the 2 sets of suture anchor threads at the fibular tunnel and are fixed with a screw. This technique provides the possible advantages of remnant preservation and promotion of load sharing by the repaired ATFL remnant and the reconstructed ATFL graft.

Arthroscopic Reconstruction of the Anterior Tibiotalar Ligament Using a Free Tendon Graft

“…7 When combined medial and lateral rotational instability is observed in a patient, arthroscopic reconstruction of the ATTL is a less-invasive alternative because it requires only one more portal than the conventional AM portal of arthroscopic surgery. 11,16,19 Although there are already arthroscopic repair techniques of the anterior part of the superficial DL, specifically the tibionavicular ligament, 36,37 ATTL reconstruction is a more direct approach for treating medial instability of the talocrural joint. Moreover, because the existence rate of the tibionavicular ligament is 89.6%, 6 this repair technique is not always possible.…”

“…The contralateral leg is slightly lowered to provide a wide working space. 11,16,19 Step 2: Graft Preparation…”

“…The AM portal is created medial to the anterior tibial tendon and slightly proximal to the joint line (Fig 2A). 11,16,18 A 30 2.7-or 4.0-mm-diameter arthroscope is introduced through the AM portal. The medial gutter is viewed with the ankle neutral or in a slightly dorsi-flexed position.…”

“…6 The ATTL can be observed arthroscopically. 7 There are already several reports of arthroscopic lateral ankle ligament reconstruction for the anterior talofibular ligament, [8][9][10][11] calcaneofibular ligament, [12][13][14][15][16][17] posterior talofibular ligament, 18 and lateral talocalcaneal ligament. 19 Here we describe the arthroscopic reconstruction of the ATTL using a free tendon graft (ARATTL).…”

“…(A) The ankle is positioned neutrally. The AM portal is created medial to the anterior tibial tendon (blue rectangle) and slightly proximal to the joint line 11,16,18. A 30 2.7-or 4.0-mm-diameter arthroscope is introduced through the AM portal.…”