Table 1.
Surgical Steps, Pearls, and Pitfalls
| Surgical Steps | Pearls | Pitfalls |
|---|---|---|
| Arthroscopic portal | The accessory anterolateral portal is placed to allow easy access to both fibular and talar bone hole positions. | Poor positioning of the portal makes it difficult to create a hole in the bone. |
| Creation of the talar anchor hole | The talus cartilage and ATFL remnant are good guides to the drill hole position. The drill position is located medial to the talus footprint of the ATFL and it has no cartilage area. We recommend performing the procedure under fluoroscopic guidance. |
Poor visualization might lead to damage to the ATFL or cartilage. |
| Creation of the fibular anchor hole | Peeling off the ATFL and shaving the footprint is important for reconstruction of the ligament heeling and good visualization during creation of the drill hole. The center of the fibular anchor hole is positioned about 5 mm proximal to the fibular obscure tubercle. |
Insufficient preparation would prevent biological healing. If a drill is inserted into the fibula perpendicularly, the anchor might blow out the posterior cortex of the fibula. |
| Suture lasso using an 18-gauge needle and 2-0 PROLENE | The 18G needle with a 2-0 nylon loop is inserted into the center of the ATFL and CFL complex. | Care should be taken to avoid penetrating the peroneal tendons or damaging the sural nerve. |
| Insertion of the knotless anchor into the fibula with ligament and tape | The racking hitch knot enhances fixation of the ligament. The ligament is reattached with the ankle in the dorsiflexion and valgus position. |
Once the anchor is introduced, tension in the suture cannot be controlled. |
| Insertion of the knotless anchor into the talus | A guidewire or K-wire is inserted into the talar drill hole under arthroscopy, to confirm the hole position and to avoid incorrect insertion. The knotless anchor is inserted into the talus under direct view. | If the positions of the holes are not carefully checked, incorrect insertion could occur. |
ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament.