Fig 1.

Patient position and graft preparation (patient 1). (A) The right ankle is the operative side. The surgical procedure is performed with the patient under general anesthesia in the supine position. A tourniquet is placed on the proximal thigh. The foot is suspended from the distal edge of the bed. The contralateral leg (left ankle) is slightly lowered to provide a wide working space. (B) The gracilis tendon is harvested from the pes anserinus, and a 2- or 3-strand graft is prepared. Tendon allograft is an alternative. The harvested tendon usually needs to be longer than 100 mm and contains an approximately 20-mm-long 2-strand bundle for the anterior talofibular ligament (ATFL). The length is determined on preoperative magnetic resonance imaging. The 2 ends form a 15-mm-long loop to facilitate attachment of the thread for graft delivery. The recommended graft diameter is 4.5 to 6.0 mm. Because the harvested tendon is thin and longer than 150 mm in this case, the graft is folded into a 3-strand bundle for the ATFL.