Table 1.
Key Surgical Steps, Pearls, and Pitfalls
| Key Surgical Steps | Pearls | Pitfalls |
|---|---|---|
| Harvest a hamstring tendon | The harvested tendon must usually be longer than 55 mm. The gracilis tendon is usable for ATTL reconstruction. The length is estimated on preoperative images. | A short tendon will prevent graft preparation, especially in cases in which simultaneous reconstruction of the medial and lateral ligaments is performed. |
| Create the AM portal | The ankle is neutrally positioned. The AM portal is created medially to the anterior tibial tendon. | If the AM portal is positioned too medially, creation of the AAM portal will be difficult. |
| Create the AAM portal | Before the AAM portal is created, a needle is inserted into the portal site to confirm accessibility to the talar and tibial footprints of the ATTL. | If the AAM portal is created without confirmation by the needle, the AAM portal position will not be suitable for the talar tunnel creation. |
| Create the talar tunnel | A guidewire is inserted through the AAM portal to drill the talus toward the lateral side of the talus. Intraoperative fluoroscopy is used to confirm guidewire position and direction. | If a guidewire is directed too posteriorly, the lateral cartilage of the trochlea may be damaged. If the tibial tunnel is created without fluoroscopy guidance, the risk of tunnel fracture and malposition may increase. |
| Create the tibial tunnel | Intraoperative fluoroscopy is used to confirm guidewire position and direction. The angle between guidewire direction and the long axis of the tibia on the lateral view is 20°-40°. | If the tibial tunnel is created without fluoroscopy assistance, the risk of tunnel fracture and malposition may increase. |
| Dissect the ATTL remnant | The dissection area should be minimal. | If the dissection area is too wide, the PTTL and superficial DL layers may be damaged. |
| Place the suture anchor in the tibial tunnel | If a drill wire does not reach the opposite cortex, surgeons can insert it from the anterior edge of the tunnel inlet to the posterior and proximal end. | If a drill wire does not reach the opposite cortex, the suture anchor will be positioned within the fibula cancellous bone and the graft fixation strength will be weak. |
| Fix the graft | If screw insertion into the tibial tunnel is difficult, a smaller screw should be chosen, or suture anchor fixation alone can be considered sufficient. | If the screw is too large for tibial tunnel fixation, tunnel wall fracture will occur. |
AAM, accessory anteromedial; AM, anteromedial; ATTL, anterior tibiotalar ligament; DL, deltoid ligament; PTTL, posterior tibiotalar ligament.