Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle

Abstract

Although several arthroscopic procedures for lateral ligament instability of the ankle have been reported recently, it is difficult to augment the reconstruction by arthroscopically tightening the inferior extensor retinaculum. There is also concern that when using the inferior extensor retinaculum, this is not strictly an anatomical repair since its calcaneal attachment is different to that of the calcaneofibular ligament. If a ligament repair is completed firmly, it is unnecessary to add argumentation with inferior extensor retinaculum. The authors describe a simplified technique, repair of the lateral ligament alone using a lasso-loop stitch, which avoids additionally tighten the inferior extensor retinaculum. In this paper, it is described an arthroscopic anterior talofibular ligament repair using lasso-loop stitch alone for lateral instability of the ankle that is likely safe for patients and minimal invasive.

Level of evidence: Therapeutic study, Level V.

Keywords: Ankle arthroscopy; Anterior talofibular ligament; Arthroscopic repair; Lasso-loop stitch; Lateral instability of the ankle; Self-cinching stitch.

Fig. 1

Portals (MML medial midline portal, AAL accessory anterolateral portal, TA tibialis anterior tendon, LM lateral malleolus)

Fig. 2

Placing a suture anchor. Arthroscopic view (middle, LM lateral malleolus, C cannula, R remnant of the anterior talofibular ligament)

Fig. 3

Inserting a needle into distal ATFL remnant. An 18G hollow needle with a 2-0 nylon thread is placed into distal ATFL remnant. The needle is rotated several times one way and then in the opposite direction, enlarging the nylon loop

Fig. 4

Suture relay technique. The loop of the nylon is retrieved through the ALL portal with a grasping instrument (left). One end of the anchor suture is then passed through the loop of nylon (second from the left). The nylon loop is then used to pull just the mid-portion of the anchor suture through the ATFL such that a loop of suture is created in the ATFL (middle). The free end of the suture is then passed through this loop (second from the right) and pulled tight creating a self-clinching stitch (right)

Fig. 5

Arthroscopic view. End of a remnant of the ATFL (left) is moved to a bone side (right) by pulling contralateral thread (arrowhead: End of a remnant of the ATFL, LM lateral malleolus)

Fig. 6

Square knot by turns to an axial thread using a knot pusher