Table 1.

Surgical Steps, Pearls, and Pitfalls

Surgical Steps	Pearls	Pitfalls
Anterior ankle arthroscopy	The anteromedial portal is made in a position of dorsiflexion, and the arthroscope is placed to see the lateral gutter.	A lack of dorsiflexion will result in poor visualization of the lateral gutter.
Lateral gutter preparation	Everything between the AITFL and the ATFL has to be removed.	Inadequate clearance will make correct placement of the tunnel difficult.
Malleolar tunnel	The arthroscope is used in portal 2 and the instruments in portal 3.	Poor placement of portal 3 can result in misdirection of the malleolar tunnel.
Tendoscopy	The arthroscope is introduced in portal 4 and the instruments in portal 3. After good preparation, the arthroscope is switched to portal 3 and the instruments to portal 2.	It is important to identify the posterior tibiofibular ligament because this can be mistaken for the CFL.
Talar tunnel	The talar tunnel is placed at a point halfway up the anterior border of the lateral facet of the talus.	Care has to be taken to avoid the tunnel running into the subtalar joint.
Malleolar tunnel	The arthroscope is placed in portal 2 and the instruments in portal 3.	It is important not to miss the remnant fibers of the CFL.
Placement of calcaneal tunnel	The arthroscope is placed in portal 3 and the instruments in portal 2.	It is necessary to protect the peroneal structures from damage.
Position of transplant in malleolar tunnel	The arthroscope is in portal 2 and the transplant in portal 3. The surgeon pulls on the toggle-lock suture.	If the transplant is too large, it will not go sufficiently far into the 6-mm tunnel.
Placement of transplant in malleolar tunnel	Tension is made with the foot at 90°.	It is important to put the screw guide deep inside to yield good placement of the screw.
Placement of calcaneal end of transplant	Tension is made with the foot at 90°.	The surgeon uses a suture to maintain tension on the graft; otherwise, the CFL reconstruction will be too loose.
Placement of talar end of transplant	Tension is made with the foot at 90° by pulling on 1 post of the JuggerKnot anchor. The transplant is fixed in the tunnel by the screw.	It is important to maintain the tension on the JuggerKnot. If it is too weak, the surgeon instead can pass the guidewire through onto the medial side of the talus with a pulling suture linked to the transplant to draw it through to the correct tension.