Arthroscopic Double-Row Repair for Acute Proximal Detachment of the Lateral Collateral Ligament in a Complex Ankle Sprain

Abstract

Management of ankle sprains is still being discussed. For athletes, recent studies recommend surgical treatment for acute grade III rupture, because of better long-term ankle stability. The purpose of this technical note is to describe the arthroscopic acute double-row repair for proximal disinsertion of collateral lateral ligament ankle. With the patient in dorsal decubitus under spinal anesthesia, the foot and ankle are extended beyond the edge of the surgical table. The anteromedial portal is created inside the anterior tibial tendon in which the arthroscope is introduced. The anterolateral approach is simulated with a needle under arthroscopic control, in front and under the tip of the lateral malleolus. The anterior talofibular ligament (ATFL) is released from the capsule with a beaver blade. The tip of the lateral malleolus is sharpened, and a soft anchor is impacted there. ATFL is caught with a Mini-Scorpio plier, a Lasso loop is performed to improve tissue grasping. The ligament is pressed against the anchor, with the foot in maximum dorsiflexion and eversion. A knotless anchor is impacted 5 mm above and with the threads of the soft anchor, creating a double-row fixation. The arthroscopic acute double-row repair for proximal desinsertion of collatéral lateral ligament ankle can be done especially for athletes.

Fig 1

(A) The patient is in the supine position with the foot hanging over the operating table, and a triangular cushion is placed under the homolateral buttock to create medial rotation of the foot and facilitate access to the anterolateral gutter and a pneumatic tourniquet at the root of the thigh. (B and C) Anatomical landmarks for the anteromedial portal

Fig 2

Anatomical landmarks for arthroscopy. Anterior tibial tendon and the medial malleolus for the anteromedial portal and tip of the lateral malleolus for the anterolateral portal

Fig 3

Lateral portal simulation with a needle, with the arthroscope in the anteromedial portal. LGT, lateral grove of talus; LM, lateral malleolus.

Fig 4

Release of the anterior talofibular ligament (blue arrow) with a beaver blade (black star) with the arthroscope in the anteromedial portal.

Fig 5

Visualization of the ligament detachment (yellow arrows denote bald malleolus) with the arthroscope in the anteromedial portal.

Fig 6

Illustration of the ligament detachment.

Fig 7

Debridement of the tip of the lateral malleolus with the shaver (black star) in the anterolateral portal (LGT, lateral groove of talus) and the arthroscope in the anteromedial portal.

Fig 8

(A) Drill guide (black star) in the anterolateral portal on the foramen obscure (LGT, lateral groove of talus) with the arthroscope in the anteromedial portal. (B) Soft anchor (red arrow) positioned at the tip of the lateral malleolus by the anterolateral portal with the arthroscope in the anteromedial portal. LGT, lateral groove of talus.

Fig 9

One of the 2 anchor sutures (red arrow) is put in the Mini Scorpion (yellow star).

Fig 10

(A-C) Grasping of the distal end of the anterior talofibular ligament (ATFL) with one of the 2 anchor sutures, with a Mini Scorpion (yellow star) in the anterolateral portal and the arthroscope in the anteromedial portal. LGT, lateral groove of talus; LM: lateral malleolus.

Fig 11

(A and B) Tension of the lateral ligament complex and anterior talofibular ligament (ATFL) is applied to the debrided area by pulling on the wire. LGT, lateral groove of talus.

Fig 12

Placing the second anchor (green star) above the first for the double row by the anterolateral portal with the arthroscope in the anteromedial portal. ATFL, anterior talofibular ligament; LGT, lateral groove of talus.

Fig 13

Final view of the double-row repair (blue arrow denotes first row; green arrow denotes second row) with the arthroscope in the anteromedial portal. ATFL, denotes anterior talofibular ligament; LGT, lateral groove of talus.

Fig 14

Lateral illustration of the final assembly with implants. Yellow star denotes first-row repair with the soft anchor; blue star denotes second-row repair with the knotless anchor. ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament.