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. 2025 Sep 1;26(1):827.
doi: 10.1186/s12891-025-08994-1.

Fibula single-tunnel versus fibula double-tunnel for both anterior talofibular ligament and calcaneofibular ligament reconstruction: a biomechanical comparison

Jingyue Gan  1   2 , Haifeng Liang  1   3 , Dongtai Li  1 , Yiran Yan  1 , Zhongxun Liu  1 , Yan Chen  4 , Bo Yu  5
Affiliations

Fibula single-tunnel versus fibula double-tunnel for both anterior talofibular ligament and calcaneofibular ligament reconstruction: a biomechanical comparison

Jingyue Gan et al. BMC Musculoskelet Disord. .

Abstract

Background: Anatomic ligament repair surgery, despite being a tremendous technical challenge in treating chronic lateral ankle instability patients, remains the gold standard for this condition. The fibula single-tunnel and double-tunnel techniques are effective for intraoperative reconstruction of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). However, which approach is more appropriate is a subject of debate.

Methods: Twelve fresh frozen cadaveric ankles were randomly divided into 2 groups of 6 specimens: fibula single-tunnel reconstruction group and fibula double-tunnel reconstruction group. The specimens were tested for ankle joint laxity on the plane radiographs with 150 N anterior drawer force and 150 N varus stress force. The anterior talar displacement and talar tilt angle were measured at states of intact, cut and reconstruction of both ATFL and CFL. Then, the reconstructed specimens were loaded to ultimate failure to determine the strength and stiffness of each construct.

Results: There were no significant differences between the two groups in the anterior talar displacement and talar tilt angle at the states of intact, cut and reconstruction of both the ATFL and CFL. There were no significant differences between the two groups in the ultimate load failure and stiffness after reconstruction of both the ATFL and CFL.

Conclusions: In patients undergoing ligament reconstruction surgery for ankle instability, both single-tunnel reconstruction of the fibula and double-tunnel reconstruction of the fibula were able to achieve better results. There was no significant difference between these two surgical procedures in our study. The long-term survival of the ankle joint after both techniques remains to be studied.

Keywords: Anterior talofibular ligament; Biomechanical; Calcaneofibular ligament; Chronic ankle instability; Ligament reconstruction.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Ethical approval for this study was obtained from the institutional review board of the Affiliated Dalian Municipal Friendship Hospital of Dalian Medical University (Approval ID: YY-LL-2022-023). Written informed consent was obtained from donor's next of kin for medical treatment and research. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
The surgical procedure of both ATFL and CFL reconstruction. A The curvilinear incision was made from talar attachment of the ATFL to the distal posterior fibula. B Exposing the ATFL and CFL. C Cutting off the ATFL. D Cutting off ATFL and CFL. E The anterior half of the peroneus longus tendon. F Drilling the fibula single-tunnel and talar tunnel. G Fibula single-tunnel reconstruction of both ATFL and CFL. H Drilling the fibula double-tunnel and talar tunnel. I Fibula double-tunnel reconstruction of both the ATFL and CFL. ATFL: anterior talofibular ligament. CFL: calcaneofibular ligament
Fig. 2
Fig. 2
Radiological measurements of the anterior drawer test and varus stress test. A The talar anterior displacement was measured. B The varus tilt angle was measured. Hexagram points to the calibrated radiopaque marker, diameter = 25.0 mm
Fig. 3
Fig. 3
The ankle specimen was secured on the custom wooden jig and mounted to the load actuator of a dynamic tensile testing machine before biomechanical testing. A The foot was placed in an inversion of 20° and plantar flexion of 10°. B A 5.0 mm diameter Steinmann pin was used to make an 80.0 mm deep guiding hole from posterior to anterior into the calcaneus to fix the hind foot rigidly
Fig. 4
Fig. 4
This graph shows no significant difference in the mean anterior displacement between Group I and Group II (P >0.05)
Fig. 5
Fig. 5
This graph shows no significant difference in the mean varus tilt angle between Group I and Group II (P >0.05)
Fig. 6
Fig. 6
Box plots comparing biomechanical data between the two groups. The horizontal line within the box indicates the median. Each box extends from the 25th to 75th percentile. The vertical bars represent the smallest and largest observed values. There are no significant differences in the ultimate failure load and stiffness between Group I and Group II (P >0.05). A Ultimate load to failure in Newtons (N). B Stiffness in Newtons per millimeter (N/mm)
Fig. 7
Fig. 7
The mechanism of failure for specimen. A The graft avulsion at the calcaneus tunnel interface in fibula single-tunnel reconstruction group. B The fracture of fibular tunnel wall in fibula double-tunnel reconstruction group
Fig. 8
Fig. 8
The ”safe zone”. The quadrangle points to ATFL insertion. The triangle points to CFL insertion. ATFL: anterior talofibular ligament. CFL: calcaneofibular ligament
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References

    1. Sammarco VJ. Complications of lateral ankle ligament reconstruction. Clin Orthop Relat Res. 2001;391:123–32. - PubMed
    1. Fujii T, Kitaoka HB, Watanabe K, Luo ZP, An KN. Comparison of modified Broström and Evans procedures in simulated lateral ankle injury. Med Sci Sports Exerc. 2006;38(6):1025–31. - PubMed
    1. Jung HG, Shin MH, Park JT, Eom JS, Lee DO, Lee SH. Anatomical reconstruction of lateral ankle ligaments using free tendon allografts and Biotenodesis screws. Foot Ankle Int. 2015;36(9):1064–71. - PubMed
    1. Korkala O, Sorvali T, Niskanen R, Haapala J, Tanskanen P, Kuokkanen H. Twenty-year results of the Evans operation for lateral instability of the ankle. Clin Orthop Relat Res. 2002;405:195–8. - PubMed
    1. Krips R, Brandsson S, Swensson C, van Dijk CN, Karlsson J. Anatomical reconstruction and Evans tenodesis of the lateral ligaments of the ankle. Clinical and radiological findings after follow-up for 15 to 30 years. J Bone Joint Surg Br Volume. 2002;84(2):232–6. - PubMed

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