Table 2.
Pearls and Pitfalls of Procedure
| Pearls | Explanation |
|---|---|
| No distraction system is required. Ankle dorsiflexion during the procedure is a key to success. | The dorsiflexion method for anterior ankle arthroscopy creates an anterior working space and relaxes the anatomic structure during the procedure, thus lowering the rate of complications. |
| The surgeon should create the medial portal as close as possible to the center of the joint—just medial to the TAT—in full dorsiflexion at the level of the joint line. | This facilitates access to the lateral gutter. Most work is performed with the arthroscope in the medial portal, and the working instruments are inserted through the accessory lateral portal. |
| The surgeon should use the surgical blade only to cut the skin. | This prevents iatrogenic injuries. |
| The surgeon should use blunt dissection (our suggestion is to use a mosquito clamp) to create the portals and to prepare the subcutaneous tissue. | This prevents iatrogenic injuries. |
| The accessory lateral portal should be created under direct control with the arthroscope in the medial portal. | A needle is used to confirm that the portal will permit adequate instrument orientation before incision. Transillumination helps to reduce iatrogenic damage to the superficial nerves and vessels. |
| Inspection and dissection of the remnant of the ATFL comprise a key to success. | This is decisive for the outcome of the procedure. At this point, a final decision is made either to proceed as planned or to perform another repair or reconstruction technique. |
| The surgeon should debride the tip of the lateral malleolus until reaching bleeding bone before putting the anchors in place. | This step will enhance the biological reaction, thus facilitating the healing of the ligament. |
| The surgeon should take care to keep the anchor guide in place and in the same direction while drilling the bone tunnel and until the anchor is finally tapped in place. | If the direction of the guide changes during the procedure, it might result in failure of anchor deployment. |
| Immediately after putting the anchor in place, the surgeon should confirm pullout resistance and also that both ends of the anchor are adequately sliding. | If there is some problem impairing proper functioning of the anchor, this is the most adequate time to solve it. |
| The surgeon should make sure to keep both ends of each anchor always connected. | This prevents confusion and mistakes during the procedure, which could cause messing of the wires between both anchors and result in secondary errors. |
| The surgeon should avoid over-tensioning of the structures and always confirm that passive full dorsiflexion and plantar flexion are possible after ligament repair. | Excessive tension might cause secondary complaints after Broström-Gould repair. |
| Pitfalls | |
| The use of a needle as a suture passer can be considered a pitfall. | It might cause iatrogenic damage within the joint and to the ATFL remnant. More adequate instruments might be developed in the future. |
| The surgeon should avoid making multiple perforations when passing through the ATFL remnant with the 18-gauge needle. | This might cause iatrogenic damage to the remnant of the ligament. |
ATFL, anterior talofibular ligament; TAT, tibialis anterior tendon.