Table 1.
Pearls and Pitfalls of Key Surgical Steps
| Key Surgical Step | Pearls | Pitfalls |
|---|---|---|
| Creation of AM portal | The ankle is positioned neutrally. The AM portal is created medial and slightly proximal to the joint line. | If the AM portal is created too medially or too distally, visualization of the ATFL remnant will be difficult. |
| Creation of 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 talar footprint of the ATFL superior limb. | If the AAL portal is created without confirmation by the needle, the AAL portal position will not be suitable for talar tunnel creation. |
| Creation of 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 toward the distal end of the medial malleolus. | A guidewire may slip at the ATFL talar footprint without marking. If the guidewire is directed too posteriorly, the neurovascular bundle is at risk of damage. If the tunnel is deeper than 20 mm, the risk of talar penetration may be higher. |
| Creation of ST portal | The ST portal is created just below the distal end of the fibula after confirmation of accessibility to the fibular footprint by a needle. | If the ST portal is created too anteriorly, the fibular tunnel direction will be distal and the risk of tunnel fracture will be higher. |
| Creation of fibular tunnel | Intraoperative fluoroscopy is used to confirm the guidewire insertion position and direction. The insertion point should be proximal to the articular tip and the FOT. | If the fibular tunnel is created without fluoroscopic assistance, the risks of tunnel fracture and malposition may be higher. If the fibular tunnel is created below the FOT, the CFL footprint may be damaged. |
| Suture anchor placement | A soft suture anchor, which has 2 sets of threads, is placed at the fibular cortex behind the fibular tunnel. | If the suture anchor is placed inside the fibular bone, the fixation strength will be weak and the suture anchor may drop out during surgery. |
| ATFL remnant repair | An 18-gauge hollow needle or a suture passer penetrates the ATFL inferior limb remnant to grab the ATFL remnant using the lasso-loop technique. | If a smaller amount of the ATFL remnant is grasped, the mechanical strength of the remnant repair via a lasso loop will weaken. |
| Graft fixation | The graft is fixed with a screw in the talar tunnel first. Subsequently, the ATFL remnant and the ATFL graft are tightened simultaneously by pulling the 2 sets of suture anchor threads at the fibular tunnel. | If the graft is fixed in the fibular tunnel first, the remnant and the graft cannot be tightened simultaneously because neither shares the load. |
AAL, accessory anterolateral; AM, anteromedial; ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; FOT, fibular obscure tubercle; ST, subtalar.