Table 1.
Key Surgical Steps, Pearls, and Pitfalls
| Key Surgical Steps | Pearls | Pitfalls |
|---|---|---|
| Harvesting a hamstring tendon | The harvested tendon usually needs to be longer than 175 mm. A semitendinosus tendon is harvested if the gracilis is too thin or too short. The length is determined by preoperative images. | Too short a tendon will make it difficult to prepare the graft. |
| Creation of the AM portal | The ankle is positioned in neutral position. AM portal is created medial to the anterior tibial tendon. | 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 guidewire is inserted through the AAL portal to drill the talus toward the distal end of the medial malleolus. | If a guidewire is directed too posterior, the neurovascular bundle is at risk for damage. If the tunnel is deeper than 20 mm, the risk of the talar penetration may be greater. |
| Creation of the ST portal | The ST portal is created just below the FOT after confirming accessibility to the fibular footprint by needle. | If the ST portal is created too anteriorly, fibular tunnel direction will be distal, and the risk of tunnel fracture will be greater. |
| Creation of the fibular tunnel | Intraoperative fluoroscopy is used to confirm the guidewire position and direction. | If fibular tunnel is created without fluoroscopy assistance, the risk of the tunnel fracture and tunnel malposition may be greater. |
| Dissection of the CFL remnant and the LTCL remnant | The shaver opening can be safely directed toward the calcaneus during the remnant dissection. | If the shaver opening is directed to lateral or distal, the peroneal tendon may 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 may happen. |
| Placement of the suture anchor to the fibular tunnel | If a drill wire does not reach the opposite cortex, the surgeon can insert it from anterior from anterior edge of the tunnel inlet to the posterior and proximal. | If a drill wire does not reach the opposite cortex, the suture anchor will be placed within the fibula cancellous bone and the graft fixation strength will be weak. |
| Graft fixation | If the screw insertion is too hard in the fibular tunnel, a smaller screw should be chosen, or the suture anchor fixation alone is enough. | If the screw is too big for the fibular tunnel fixation, the tunnel wall fracture will occur. |
AAL, accessory anterolateral; AM, anteromedial; ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; FOT, fibular obscure tubercle; LTCL, lateral talocalcaneal ligament; ST, subtalar.