Fig 5.

Tendon graft introduction (left ankle). (A) Viewed from the AM portal, the surgeon penetrates from the tibial tunnel bottom to the opposite cortex using a 2.9-mm drill wire (Zimmer-Biomet, Warsaw, IN) through the AAM portal. A JuggerKnot Soft Anchor 2.9 mm (Zimmer-Biomet) is placed at the tibial cortex behind the tibial tunnel. (B) Then, 1.6-mm passing pins (Meira Co., Ltd., Nagoya, Japan) are inserted into the talar tunnel through the AAM portal. The pins penetrate the bone and skin on the opposite side. A looped thread is passed through the eye of each passing pin, which is completely pulled. (C) The looped thread in the talar tunnel is connected to the talar graft end and the ATTL graft is introduced from the AAM portal to the talar tunnel by pulling of the looped thread. One strand of the suture anchor thread is sutured to the tibial side end of the graft, whereas the other strand is pulled to introduce the graft to the tibial tunnel. (Patient 1 is shown in all panels.) (AAM, accessory anteromedial; AM, anteromedial; ATTL, anterior tibiotalar ligament.)