Table 2.

Pearls and Pitfalls

Surgical Technique Steps	Pearls	Pitfalls
Arthroscopic portals	-Two portals only: Standard anteromedial portal (made in a dorsiflexion position) and modified anterolateral one (made under arthroscopic vision).	-Unmarking the intermediate branch of superficial peroneal makes it liable to injury. -Poor placement of the modified anterolateral portal will make correct placement of the fibular tunnel through the portal difficult.
Lateral gutter preparation	-Synovitis and intra-articular scar tissue should be resected. -Radiofrequency ablation may be used.	-Inadequate clearance will make the following steps more difficult. -Aggressive debridement could damage the joint capsule.
Creation of tunnels	-The fibular tunnel is performed with an inclination of 30 degrees from the longitudinal axis of the fibula in the sagittal plane in a posterosuperior direction. -The talar tunnel is placed at a point just in front of the tip of distal fibula directed toward the most posterior point of the medial malleolus. -The arthroscope is introduced in the anterolateral portal to ensure correct direction of the fibular and talar tunnels.	-Misdirection of the fibular tunnel could lead to its splitting. -Be careful during outward passage of the fibular tunnel guidewire because this could injure the peroneal tendons. -Care has to be taken to avoid the tunnel running into the subtalar joint.
Graft passage	-Verification of anchorage of the button to the posterior fibular cortex as well as adequate insertion of the graft in the fibular tunnel.	-Inadequate widening of the space between peroneal tendons and calcaneus makes passage of calcaneofibular limb difficult.
Graft fixation	-Fixation of the talar limb is performed with the ankle in slight dorsiflexion and slight eversion. -Fixation of the calcaneal limb is done while the ankle is in a slight plantar flexion.	-It is important to ensure the final tension of the graft and readjust it by pulling the TightRope sutures again. -If we are not sure about stable anchorage of the fibular button or fibular tunnel is too wide, fibular fixation could be enforced by a tenodesis screw inserted through the anterolateral portal.