Arthroscopic Repair of Acute Proximal Detachment of the Medial Collateral Ligament in a Complex Ankle Sprain

Abstract

Management of ankle sprains is still being discussed. Repair of the deltoid ligaments is suggested in patients with medial ankle instability after a ligamentous injury or malleolar fracture fixation. The purpose of this technical note is to describe an arthroscopic technique for acute repair of proximal detachment of medial collateral ligament of the ankle. With the patient in supine position under spinal anesthesia, the foot and ankle are extended beyond the edge of the surgical table. The standard anteromedial and anterolateral portals are used. An accessory portal, inferior to the medial malleolus, is simulated with a needle under arthroscopic control. The tip of the medial malleolus is debrided, and a soft anchor is impacted there. A Lasso loop is passed twice to the medial collateral ligament to improve the grasp and to perform a U‐shaped stitch. The ligament is pressed against the anchor, with the foot in maximum dorsiflexion. The arthroscopic acute repair for proximal disinsertion of medial collateral ligament ankle appears to be a reliable and reproducible technique.

The deltoid ligament complex is the primary stabilizer against valgus force in the ankle. However, there is increasing recognition that medial ligamentous injuries may be more frequently associated with ankle sprains, ¹ syndesmotic injuries, ² and fractures ³ than previously reported. Acute surgical repair is not commonly proposed after acute medial collateral ligament (MCL) complex injuries, and conservative treatment is generally favored. ⁴ , ⁵ However, a number of patients undergoing conservative treatment may develop medial ankle instability. ⁶ , ⁷ Magnetic resonance imaging is often considered the noninvasive gold standard to assess ligamentous injuries. ⁸ Recently, some authors have developed arthroscopic techniques to treat MCL ligament injuries with excellent results. ⁹ , ¹⁰ , ¹¹ This technical note describes an arthroscopic repair technique of acute proximal detachment of the MCL with early rehabilitation.

SURGICAL TECHNIQUE

Surgical repair of acute proximal detachment of the MCL is presented in Video 1.

VIDEO 1.

Download video file ^{(90.2MB, mp4)}

The patient is positioned supine with the foot hanging over the edge of the operating table to allow full dorsiflexion, and a cushion is placed under the ipsilateral buttock to maintain neutral rotation. This video illustrates the complete arthroscopic technique performed on a right ankle. After diagnostic arthroscopy through the anterolateral portal, the medial gutter is visualized and soft‐tissue debris is removed to expose the bald medial malleolus, confirming proximal medial collateral ligament (MCL) avulsion. Under arthroscopic guidance, a needle is used to localize the accessory medial portal, positioned anterior and inferior to the medial malleolus. A drill guide is then introduced through this portal to create a 1.8‐mm bone tunnel in the anterior colliculus, followed by insertion of a DX FiberTack knotless soft anchor (Arthrex). Using a SutureLasso, the blue suture is passed twice through the MCL, first posteriorly and then anteriorly. With the ankle in maximal dorsiflexion, the medial ligament complex is tensioned and secured by advancing the knotless mechanism. The final construct restores the anatomic footprint of the MCL on the medial malleolus. This technical note describes an arthroscopic U‐shaped stitch suture technique, accompanied by a video illustration. Video content can be viewed at https://doi.org/10.1002/atn2.70127.

Surgical Preparation

The patient is placed in the supine position with spinal or general anesthesia (Figure 1A‐C). The foot hangs over operating table to allow dorsal flexion of the ankle. A triangular cushion is placed under the homolateral buttock to create neutral rotation of the foot to access medial gutter. A pneumatic tourniquet is placed at the root of the thigh and inflated to 300 mmHg. Prophylactic antibiotics are administered, according to the guidelines of the French Society for Anesthesia and Resuscitation.

FIGURE 1.

(A) The patient is placed in the supine position with the left foot hanging over the operating table to allow flexion dorsal of the ankle, and a triangular cushion is placed under the homolateral buttock to create neutral rotation of the foot and a pneumatic tourniquet at the root of the thigh (B,C).

Equipment

A 4‐mm 30° arthroscope and a 3‐mm bone/soft‐tissue shaver are used. DX FiberTack (Arthrex, Naples, FL) soft anchors with nonabsorbable sutures are used for ligament fixation. A SutureLasso 70 (Arthrex, Naples, FL) is also used.

Arthroscopic Portals and Exploration

The anatomical references used are the anterior tibial tendon and the lateral malleolus. ⁹ The branching of the superficial peroneal nerve is identified subcutaneously by inverting the foot. The anteromedial portal is positioned directly medial to the tibial tendon next to the joint space and the standard anterolateral portal is used throughout the procedure (Figure 2). The arthroscope is inserted for complete exploration of the joint and to identify any associated injuries (cartilage, syndesmosis, lateral collateral ligament, etc.). The debridement of the medial gutter is addressed with the arthroscope in the anterolateral portal (Figure 3).

FIGURE 2.

With the patient supine and the ankle in dorsiflexion, anatomical landmarks for left ankle arthroscopy are identified. The anteromedial portal is placed lateral to the medial malleolus and medial to tibialis anterior tendon. The anterolateral portal is made under direct visualization, medial to the lateral malleolus. One should be caution to avoid the superficial peroneal nerve.

FIGURE 3.

Supine position with the ankle in dorsiflexion and neutral rotation. This is an external view of the right ankle. The anterolateral portal is used for the arthroscope and the anteromedial portal is used for the shaver. The debridement of the medial gutter can be performed.

Bone Surface and Ligament Preparation

Once the deltoid ligament injury is documented (Figures 4 and 5) and the soft tissue debrided off the anterior and the tip of the medial malleolus, it is time for placement of the suture anchor. With a needle under arthroscopic guidance (Figure 6), an accessory portal is made inferior to the medial malleolus to facilitate anchor placement. A drill guide is positioned on the anterior colliculus (Figure 7A) to drill a 1.8 mm hole to a depth of 10 mm. A DX FiberTack (Arthrex, Naples, FL) soft anchor is positioned with the same guide (Figure 7B) at the tip of the medial malleolus. The anchor is impacted and confirmed to be stable by a gentle tug on the sutures. Using the SutureLasso Loop (Arthrex, Naples, FL), the first pass of the blue suture is made percutaneously posteriorly to the accessory portal through the MCL (Figure 8). The blue suture is retrieved with a grasper and pulled out through the accessory portal, remaining outside the ligament (Figure 9). Next, the same blue suture is passed a second time, this time more anteriorly, again using the SutureLasso Loop (Arthrex, Naples, FL). This creates a U‐shaped stitch configuration, with the suture passing twice through the ligament, first posteriorly and then anteriorly (Figure 10).

FIGURE 4.

Arthroscopic view of the medial gutter of the right ankle through the anterolateral portal. Identification of the MCL detachment (white arrows denote bald malleolus).

FIGURE 5.

Schematic illustration of a right ankle showing proximal detachment of the MCL from the medial malleolus. (MCL, medial collateral ligament.)

FIGURE 6.

Arthroscopic view of the medial gutter of the right ankle through the anterolateral portal. A needle is inserted under arthroscopic guidance to localize and establish the accessory portal, positioned anterior and inferior to the medial malleolus for anchor insertion. (MM, medial malleolus; MGT, medial grove of talus.)

FIGURE 7.

Arthroscopic view of the medial gutter of the right ankle through the anterolateral portal. (A) A drill guide (black star) is introduced through the accessory portal on the anterior colliculus to drill a 1.8 mm hole to a depth of 10 mm. (B) A soft anchor (red arrow) is inserted at the tip of the medial malleolus through the same guide.

FIGURE 8.

(A) Schematic drawing showing the posterior suture passage in a right ankle. (B) External view of right ankle showing percutaneous insertion of the SutureLasso loop posterior to the accessory portal to shuttle the blue suture through the posterior portion of the MCL. (MCL, medial collateral ligament.)

FIGURE 9.

External view of a right ankle. An arthroscopic grasper is inserted through the accessory portal to retrieve the blue wire and bring it out of the ligament, ensuring correct positioning before the anterior suture passage.

FIGURE 10.

On the left (A), an external view of a right ankle; the right (B) shows a schematic drawing illustrates the suture passage. The same blue suture is passed a second time, this time more anteriorly, again using the SutureLasso Loop. The foot is placed in maximal dorsal flexion. Tension of the medial ligament complex is obtained by passing the blue suture through the black and white loop.

Ligament Repair and Fixation

The foot is placed in maximal dorsal flexion. Tension of the medial ligament complex is obtained by passing the blue suture through the black and white FiberLink loop. Pull the SutureTape end of the FiberLink suture axially to the anchor insertion using small, short tugs to advance the knotless mechanism through the anchor (Figure 11). Pull the blue suture in an axial motion to tighten the knotless stitch. The suture is evened out with a suture cutter, and correct repair is confirmed with a probe.

FIGURE 11.

Medial schematic view of a right ankle showing the completed U‐shaped stitch, restoring the anatomic footprint of the MCL. (MCL, medial collateral ligament.)

The incisions are closed with separate nonabsorbable 3/0 suture without a drain. The ankle is wrapped in a flexible elastic bandage, and the tourniquet is deflated.

Postoperative Protocol

Immediate full weight‐bearing is allowed with a walking boot, which should be worn for 2 weeks, night and day. Cryotherapy should be begun in the postoperative recovery room and continued for 2 weeks. No anticoagulation therapy is prescribed. Level 1 or 2 analgesics and nonsteroid anti‐inflammatories are systematically prescribed for the first 2 days to prevent postoperative pain. Crutches may be used for the first week to limit weight‐bearing in case of pain or apprehension. Physical rehabilitation begins after 2 weeks with the goal of normal physiological walking at 1 month. The patient may return to running at 6 weeks and contact pivot sports after between 2 and 3 months depending on the results of return to sport tests.

DISCUSSION

This technical note describes an arthroscopic technique to repair acute deltoid ligament detachment (Table 1). Under arthroscopic visualization, the most accurate diagnosis of medial instability can be determined. Also, with arthroscopy, a precise assessment can also be made of any associated injuries, which can also sometimes be treated (cartilage, syndesmosis, and lateral collateral ligament). Management of these associated lesions has already been shown to be important in the outcome of chronic ankle instability. ¹²

TABLE 1.

Advantages and Disadvantages of the Technique

Advantages	Disadvantages	Limitations
The technique can be performed with the usual arthroscopic instruments	Sensory branch of the superficial fibular nerve is at risk with anterolateral portal placement	Only for acute MCL detachment
Low rate of complications	Learning curve	The procedure is indicated in a limited number of patients
Reduced risk of skin complications (necrosis, infection, and delayed healing) compared with open procedures	Clinical studies are needed to validate this technique
One‐day surgery
Full weight‐bearing immediately after the procedure and quicker recovery compared with open procedures
Minimally invasive surgery

MCL, medial collateral ligament.

Deltoid ligament rupture is commonly associated with ankle fracture. Hintermann et al. ¹³ reported that >40% of ankle fractures had a deltoid ligament injury discovered through arthroscopic examination. Recent studies suggest that there is a role for acute repair of the deltoid ligament. ¹⁴ , ¹⁵ Several authors emphasize that a nonanatomic healing of the deltoid ligament complex injury is known to negatively affect clinical and functional outcomes in short‐ and long‐term follow‐up. ¹⁵ , ¹⁶ Furthermore, the conservative management of acute MCL injuries, particularly in complex ankle sprains or bimalleolar‐equivalent fractures, may result in persistent instability, chronic medial ankle pain, and progression to osteoarthritis. ¹⁵

Of note, some authors have previously published techniques for arthroscopic repair of deltoid ligament. Kim's technique ¹⁰ uses a single anchor with 2 sutures and describes a safe zone, but no follow‐up outcomes or anatomical validation were reported. Also, Vega et al. ¹¹ used a suture passer to pierce the ligament and passing a double suture in a looped configuration. The anchor was then inserted on the anteromedial aspect of the medial malleolus using a knotless fixation system. Twelve of 13 patients returned to daily activities with no discomfort, whereas the other patient had medial ankle pain.

The deltoid ligament complex is primarily divided into superficial and deep components. In previous studies, the deep deltoid ligament was considered the major contributor to ankle stability against a valgus load, and the superficial deltoid ligament was considered to contribute only minimally to stability. ¹⁷ , ¹⁸ , ¹⁹ Arthroscopic U‐shaped stitch repair of acute deep medial ligament complex injury of the ankle seems to be a reliable technique (Table 2). Clinical studies are necessary to evaluate the rate of recurrence and complications, and to compare acute arthroscopic repair with functional treatment or open surgery, which are still the gold standard in ankle sprains.

TABLE 2.

Pearls and Pitfalls of Arthroscopic Acute Repair of Detachment of the MCL

Step	Pearls	Pitfalls
Installation	Place a triangular wedge pillow under the homolateral buttock to place the ankle in neutral rotation to access the medial groove	If the accessory portal is badly positioned, all of the procedures cannot be performed (positioning of the suture anchors and preparation of the ligament).
Endoscopic portals	The contralateral leg can be lowered to prevent interference with the arthroscopic procedure.	Carefully drill on the sagittal plane of the medial malleolar to avoid articular injury from the drill.
Ligament preparation	Identify the branching of the fibular nerve subcutaneously in inversion and plantar flexion of the 4th toe.	Do not retrieve the blue suture subcutaneously, as there is a risk of passing over the saphenous vein
Fixation	Grasp as much of ligament tissue as possible with 2 sutures passage to MCL to improve the strength of the ligament fixation.

MCL, medial collateral ligament.

DISCLOSURES

The author (R.L.) declares the following financial interests/personal relationships which may be considered as potential competing interests: R.L. has received consulting fees from Arthrex, royalties from Serf extremity, Orthonov and ISO (Implant Service Orthopedie). The other author (M.C.) declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.