Fig 5.

Tendon graft introduction (the left ankle). (A) Viewed from the AAL portal, surgeon penetrated from the fibula tunnel bottom to the opposite cortex with a 2.9-mm drill wire (Zimmer-Biomet) through the ST portal. A JuggerKnot Soft Anchor-2.9 mm (Zimmer-Biomet) is placed at the fibula cortex behind the fibular tunnel. Passing pins of 1.6 mm (Meira Corporation, Ltd.) are inserted to the talar tunnel through the AAL portal and inserted to the calcaneal tunnel through the ST portal. These pins penetrate the bone and the skin on the opposite side. A looped thread is passed to the eye of each passing pin. The passing pins are completely pulled. By pulling the looped thread in the talar tunnel, 2 looped threads are relayed into the talar tunnel. (B) Viewed from the AM portal, the 2 looped threads in the talar tunnel are led from the AAL portal to the ST portal by the suture retriever. (C) Each looped thread is used to induct of the talar side ends of the ATFL graft and the LTCL graft, respectively. The looped thread in the calcaneal tunnel is connected with the calcaneal graft end. Then, the common looped calcaneal end of the CFL and LTCL is introduced from the ST portal to the calcaneal tunnel by pulling the looped thread. One strand of the suture anchor thread is sutured to the fibular end of the graft, and the other strand is pulled to induct it to the fibula tunnel. Panels A and B are from patient 1. (AAL, accessory anterolateral; AM, anteromedial; ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; LTCL, lateral talocalcaneal ligament; ST, subtalar.)