Table 1.
Key Surgical Steps, Pearls, and Pitfalls
| Key Surgical Steps | Pearls | Pitfalls |
|---|---|---|
| Patient position | The foot is suspended from the distal edge of the bed. The contralateral leg is slightly lowered to provide a wide working space. | If the foot is not suspended from the distal edge of the bed, it will be difficult to dorsiflex the ankle using the surgeon's belly. |
| Harvest a hamstring tendon | The gracilis tendon is usually enough to create the graft. A semitendinosus tendon is harvested if the gracilis is too thin or too short. The harvested tendon usually needs to be longer than 160 mm. The length is determined by preoperative magnetic resonance imaging. | An extremely short tendon will be difficult to prepare the 2-strand ATFL graft. |
| Creation of the AM portal | The ankle is positioned neutrally. The AM portal is created medial to the anterior tibial tendon, which is slightly displaced laterally by pushing with the thumb. | If the AM portal is created too medially, visualization of the ATFL remnant will be difficult. |
| Creation of the AAL portal | The ankle is dorsiflexed to view the ATFL remnant. Before the AAL portal is created, a needle is inserted into the portal site to confirm accessibility to the ATFL talar footprint. | If the AAL portal is created without confirmation by the needle, the AAL portal position will not be suitable for the talar tunnel creation. |
| Creation of the talar tunnel | A microfracture awl is used to mark the center of the ATFL talar footprint, and a guidewire is inserted through the AAL portal to drill the talus towards the distal end of the medial malleolus. | A guidewire may slip at the ATFL talar footprint without marking. If a guidewire is directed too posteriorly, the neurovascular bundle is at risk for damage. If the tunnel is deeper than 20 mm, the risk for talar penetration may be higher. |
| Creation of the ST portal | The ST portal is created just below the distal end of fibula after confirming accessibility to the fibular footprint by a needle. | If the ST portal is created too anteriorly, the fibular tunnel is directed distally and the risk of tunnel fracture will be higher. |
| Creation of the fibular tunnel | Intraoperative fluoroscopy is used to confirm the guidewire position. | If the fibular tunnel is created without fluoroscopic assistance, the risk for tunnel fracture and tunnel malposition may be higher. |
| Dissection of the CFL remnant | The shaver opening can be safely directed toward the calcaneus during the CFL remnant dissection. | If the shaver opening is directed laterally or distally, the peroneal tendon might be damaged. |
| Creation of the calcaneal tunnel | A 25- to 30-mm-deep calcaneal tunnel is overdrilled through the ST portal. The drill should pass gently near the peroneal tendon. | If the tunnel is drilled through the AAL portal, the drill angle to the calcaneal surface will be too sharp and tunnel wall fracture might occur. |
| Passing pin to the fibular tunnel | A pin is inserted anteriorly from the anterior edge of the tunnel inlet to the posterior and proximal edge to penetrate the posterior cortical wall of the fibula and the skin. | If a pin is inserted parallel to the tunnel, it may not penetrate the skin on the posterior aspect, and a longer passing pin will be necessary. |
| Graft fixation | The ATFL graft should be fixed first. | If the CFL graft is fixed with extremely strong tension before the ATFL graft fixation, anterior drawer stress of the talus may occur and anterior stability will decrease. |
AAL, accessory anterolateral; AM, anteromedial; ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; ST, subtalar.