Arthroscopic-Assisted Lateral Ligamentous Reconstruction in Combined Ankle and Subtalar Instability

We describe an arthroscopic technique by which to reconstruct both the calcaneofibular ligament and anterior talofibular ligament anatomically. The ankle joint is examined through the anteromedial portal and a lateral portal close to the talar insertion of the anterior talofibular ligament. The subtalar joint is examined through the anterolateral portal and the middle portal. Associated intra-articular pathology (e.g., osteochondral defect) is evaluated and addressed. The calcaneofibular ligament is an extracapsular structure that can be examined arthroscopically through the anterolateral portal in the extra-articular plane. The peroneal tendon sheath is stripped with a small periosteal elevator through the middle subtalar portal, and the calcaneal insertion of the calcaneofibular ligament is identified. The plantaris tendon is identified and freed through multiple small wounds at the medial calf, and the tendon is cut proximally and retrieved to its calcaneal insertion. A calcaneal bone tunnel (tunnel 1) is created between the plantaris tendon and the calcaneofibular ligament insertions by use of a 3.5-mm drill bit. The tendon graft is then looped onto a suture, and the suture is passed through the tunnel to the calcaneofibular ligament insertion and retrieved to the middle subtalar portal. Through the anterolateral subtalar portal, the fibular insertion of the calcaneofibular ligament is identified. Another bone tunnel is created from this point to the posterior edge of the fibula (tunnel 2) with a 3.5-mm drill through the middle subtalar portal. The fibular insertion of the anterior talofibular ligament is identified on ankle arthroscopy. Tunnel 3 is created from this point to the exit point of tunnel 2 through the lateral ankle portal. The tendon graft is retrieved to the lateral ankle joints through the second and third tunnels and is pierced through the lateral ankle capsule and course from intracapsular to extracapsular. The tendon graft loop is anchored to the insertion point of the anterior talofibular ligament by a 4.0-mm cancellous screw with a spiked washer. The tendon graft is tensioned by pulling the free end of the tendon graft while tightening the screw. The free end of the tendon graft and the stay stitch are sutured to surrounding soft tissue or anchored with another 4.0-mm cancellous screw and spiked washer. The procedure is then completed, and a short leg cast is applied. The patient is advised to perform non-weight-bearing walking for 6 weeks.