A Simplified Percutaneous Single-Suture Technique for Chronic Lateral Ankle Instability

Introduction

Chronic lateral ankle instability (CLAI) is a frequent cause of pain, recurrent sprains, subjective instability, and functional limitation after ankle injuries. ¹ The anterior talofibular ligament (ATFL) is the structure most commonly involved and represents the primary restraint against anterior translation of the talus. ² Open Broström-type procedures provide reliable outcomes but require greater soft tissue dissection and longer recovery. ³ Minimally invasive techniques seek to reduce morbidity while maintaining mechanical stability. In addition, ankle arthroscopy allows diagnosis and treatment of associated intra-articular pathology, which is commonly present in patients with CLAI.^4,5 Although arthroscopic Broström techniques have demonstrated favorable clinical outcomes, they may require specialized instrumentation, advanced technical expertise, and present potential neurovascular risks.^{5 -7} Therefore, simplified hybrid techniques combining arthroscopy with minimally invasive percutaneous stabilization may represent an attractive alternative. The purpose of this Technical Tip is to describe a simplified percutaneous single-suture technique for lateral ankle stabilization performed after diagnostic ankle arthroscopy.

Surgical Technique

Patient Positioning and Landmarks

The patient is placed in the supine position with a bump under the ipsilateral hip to obtain slight internal rotation of the limb. A thigh tourniquet may be used according to surgeon preference. No mechanical distraction device or leg holder is routinely required, although manual distraction may be applied during arthroscopy if necessary. Surface landmarks are carefully identified and marked, including the distal fibula, fibular ATFL footprint, superficial peroneal nerve course, and planned anterior and posterior incision sites (Figure 1). Particular attention should be paid to identification and protection of the superficial peroneal nerve, especially during anterior percutaneous passage. Maintaining the needle trajectory close to the distal fibula may help minimize neurovascular risk.

Figure 1.

Surface anatomical landmarks and incision planning for percutaneous lateral ankle stabilization, including the lateral malleolus, native ATFL footprint, planned anterior and posterior percutaneous incisions, and superficial peroneal nerve course.

Arthroscopic Evaluation

Standard anterior ankle arthroscopy is first performed. Synovitis, soft tissue impingement, osteochondral lesions, and ligament status are assessed. Arthroscopy is primarily used for evaluation and treatment of associated intra-articular pathology, identification of the fibular ATFL footprint, and preparation of the insertion site. Synovectomy and debridement of the fibular ATFL footprint are completed to expose cancellous bone and optimize the biologic environment for healing (Figure 2). Direct arthroscopic repair of the ATFL was intentionally not performed in order to simplify the procedure, reduce instrumentation requirements, and maintain a reproducible minimally invasive workflow while preserving the advantages of arthroscopic joint assessment.

Figure 2.

Arthroscopic preparation of the native fibular footprint of the anterior talofibular ligament (ATFL). The asterisk indicates the prepared ATFL footprint after debridement and exposure of cancellous bone to optimize the biologic environment for healing.

Anchor Placement

An 8- to 10-mm longitudinal incision is made over the distal fibula at the native ATFL footprint. Blunt dissection is carefully carried down to bone. A suture anchor is inserted into the distal fibula approximately 5 to 8 mm proximal to the fibular tip and angled slightly proximally and anteriorly in order to optimize fixation strength and reproduce the native ATFL origin (Figure 3). Malposition of the anchor outside the native ATFL footprint or inadequate insertion angle may compromise fixation strength and tissue tensioning. One high-strength 2-0 nonabsorbable suture limb is then loaded into a curved Mayo needle for percutaneous passage. No cannulated needle system is required.

Figure 3.

Percutaneous anchor placement in the lateral malleolus at the anatomical footprint of the anterior talofibular ligament (ATFL).

Anterior Tissue Capture

A second 5- to 8-mm incision is made anterior to the distal fibula at the level of the anterolateral capsule. Blunt dissection is carefully performed through the subcutaneous tissue in order to identify the capsuloligamentous plane while minimizing risk to branches of the superficial peroneal nerve. The extensor retinaculum is identified based on its dense fibrous consistency and its location approximately 1 to 1.5 cm anterior to the fibular tip. The needle is passed from the fibular incision toward the anterior incision while maintaining a trajectory immediately anterior to the distal fibula in order to incorporate the residual ATFL tissue, anterolateral capsule, and extensor retinaculum in a single pass (Figure 4). Tactile resistance during passage and the characteristic dense consistency of the ligamentous tissue may help confirm adequate tissue capture. No arthroscopic confirmation of tissue capture is performed during this step; tissue incorporation relies on anatomical landmarks, maintenance of a trajectory close to the distal fibula, and tactile feedback during needle passage.

Figure 4.

Anterior percutaneous suture passage was performed immediately anterior to the distal fibula in order to incorporate the residual ATFL tissue, anterolateral capsule, and extensor retinaculum.

Posterior Passage

A third 5- to 8-mm incision is created slightly posterior and distal to the fibular tip in order to avoid excessive distal passage and unintended capture of the calcaneofibular ligament. Blunt dissection is carefully performed through the subcutaneous tissue. A clamp or hemostat is introduced to retract and protect the peroneal tendons during suture passage. The needle is advanced from the anterior incision toward the posterior incision while avoiding tendon entrapment and maintaining close contact with the distal fibula (Figure 5). Before final knot tying, blunt dissection is performed between the skin and underlying soft tissues using a hemostat in order to prevent skin tethering or puckering during suture tensioning.

Figure 5.

Posterior percutaneous passage was performed slightly posterior and distal to the fibular tip while protecting the peroneal tendons with a hemostat during suture advancement.

Triangular Configuration and Fixation

After exiting posteriorly, the needle is redirected toward the original fibular incision, creating a triangular construct encompassing the residual ATFL tissue, anterolateral capsule, and extensor retinaculum (Figure 6). A schematic representation of the tissue layers incorporated within the triangular construct is shown in Figure 7. Both suture limbs are retrieved through the fibular incision. With the ankle maintained in neutral dorsiflexion and slight eversion, progressive manual tensioning of the sutures is performed in order to reproduce physiologic ATFL tension. The sutures are progressively tensioned to maximize ankle stability while avoiding excessive stress or tissue cut-through during final fixation. Final stability is assessed with talar tilt testing.

Figure 6.

Final suture passage from the posterior incision to the fibular anchor site, followed by triangular construct configuration before knot tying.

Figure 7.

Schematic representation of the triangular construct and tissue layers incorporated during percutaneous lateral ankle stabilization. (A) Lateral view showing anchor placement at the ATFL footprint on the fibula (1) and suture passage to the anterior (2) and posterior (3) tissue capture points, forming a triangular configuration. (B) Cross-sectional view at the level of the construct demonstrating that the suture incorporates the extensor retinaculum, ATFL remnant, and anterolateral capsule, whereas the skin and subcutaneous tissue are not included. (C) Superior view summarizing the triangular construct. ATFL, anterior talofibular ligament.

Postoperative Protocol

The ankle is immobilized for 2 weeks with non–weight-bearing protection. Progressive weight-bearing in a walker boot is then allowed over the following 4 weeks. Range-of-motion, strengthening, and proprioceptive rehabilitation exercises are progressively initiated thereafter. Return to running and sports activities is generally permitted between 3 and 4 months depending on clinical recovery and restoration of functional stability.

Pearls and Pitfalls

Pearls

Accurate identification of the native ATFL footprint improves anatomic restoration and anchor positioning.

Maintaining the needle trajectory close to the distal fibula may improve capture of the capsuloligamentous structures while minimizing neurovascular risk.

Blunt dissection before final knot tying may help prevent skin tethering or puckering.

Progressive manual tensioning in neutral dorsiflexion and slight eversion may help preserve physiologic ankle motion while restoring stability.

Arthroscopy allows treatment of associated intra-articular pathology and preparation of the fibular insertion site.

Pitfalls

Anchor malposition or inadequate insertion angle may compromise fixation strength and tissue tensioning.

Superficial tissue-only capture may lead to persistent instability.

Excessive distal suture passage may result in unintended capture of the calcaneofibular ligament.

Excessive tension beyond the resistance capacity of the soft tissues may result in tissue cut-through during final fixation.

Failure to identify and protect branches of the superficial peroneal nerve or peroneal tendons may result in complications.

Discussion

This technique combines the advantages of ankle arthroscopy and minimally invasive percutaneous stabilization for the treatment of chronic lateral ankle instability. Arthroscopy allows identification and treatment of associated intra-articular pathology, which has been frequently reported in patients with chronic ankle instability, while also facilitating preparation of the fibular ATFL footprint.^4,5

Open Broström-type procedures remain the reference standard for surgical management of chronic lateral ankle instability because of their reproducible clinical outcomes and reliable restoration of lateral ankle stability.^2,3 However, open techniques require greater soft tissue dissection and may be associated with wound morbidity, postoperative pain, and prolonged recovery. Arthroscopic Broström techniques have emerged as a minimally invasive alternative with favorable clinical outcomes and earlier recovery profiles.^5-9 Nevertheless, arthroscopic ligament repair may require specialized instrumentation, advanced technical expertise, and careful attention to neurovascular structures. ⁹

The present technique was designed as a simplified hybrid approach combining arthroscopic joint evaluation with percutaneous soft tissue stabilization. By avoiding direct arthroscopic ligament repair, the procedure may reduce technical complexity and instrumentation requirements while preserving the advantages of arthroscopic assessment and treatment of intra-articular pathology. In addition, incorporation of the capsuloligamentous structures and extensor retinaculum through a triangular suture configuration may provide supplementary reinforcement similar to augmentation concepts described in modified Broström procedures.^3,10,11

Potential limitations of this technique include the absence of direct visualization during tissue capture, dependence on accurate anatomical landmark identification, and the potential risk of superficial peroneal nerve irritation or injury during percutaneous passage. Poor-quality or attenuated tissue may also compromise repair integrity. Furthermore, biomechanical validation and prospective clinical outcome studies are still necessary to determine long-term reproducibility, safety, and functional outcomes.

Conclusion

This simplified percutaneous single-suture technique represents a reproducible and minimally invasive option for the treatment of chronic lateral ankle instability. Combined with ankle arthroscopy, it allows management of associated intra-articular pathology while aiming to restore lateral ankle stability through a low-profile soft tissue–preserving approach. Further biomechanical and prospective clinical studies are necessary to validate the reproducibility, safety, and long-term functional outcomes of this technique.